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e. Risk-prone health behavior
ANS: A, C
Chronic low self-esteem and powerlessness are interwoven in the patient‘s statements. No
data support the other diagnoses.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 13-13, 14, 18, 33, 44 (Table 13-2)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
4. The plan of care for a patient in the manic state of bipolar disorder should include which
interventions? (Select all that apply.)
a. Touch the patient to provide reassurance.
b. Invite the patient to lead a community meeting.
c. Provide a structured environment for the patient.
d. Ensure that the patient‘s nutritional needs are met.
e. Design activities that require the patient‘s concentration.
ANS: C, D
People with mania are hyperactive, grandiose, and distractible. It is most important to
ensure the patient receives adequate nutrition. Structure will support a safe environment.
Touching the patient may precipitate aggressive behavior. Leading a community meeting
would be appropriate when the patient‘s behavior is less grandiose. Activities that require
concentration will produce frustration.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 13-18, 19 (Case Study and Nursing Care Plan), 46 (Table 13-3)
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
Chapter 14: Depressive Disorders
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1. A patient became severely depressed when the last of the family‘s six children moved out of
the home 4 months ago. The patient repeatedly says, ―No one cares about me. I‘m not worth
anything.‖ Which response by the nurse would be the most helpful?
a. ―Things will look brighter soon. Everyone feels down once in a while.‖
b. ―Our staff members care about you and want to try to help you get better.‖
c. ―It is difficult for others to care about you when you repeatedly say the same negative
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things.‖
d. ―I‘ll sit with you for 10 minutes now and 10 minutes after lunch to help you feel
that I care about you.‖
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ANS: D
Spending time with the patient at intervals throughout the day shows acceptance by the nurse
and will help the patient establish a relationship with the nurse. The therapeutic technique is
―offering self.‖ Setting definite times for the therapeutic contacts and keeping the
appointments show predictability on the part of the nurse, an element that fosters trust
building. The incorrect responses would be difficult for a person with profound depression to
believe, provide false reassurance, and are counterproductive. The patient is unable to say
positive things at this point.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-27, 57 (Table 14-4) | Page 14-16 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A patient became depressed after the last of the family‘s six children moved out of the home 4
months ago. Select the best initial outcome for the nursing diagnosis Situational low self-esteem
related to feelings of abandonment. The patient will
a. verbalize realistic positive characteristics about self by (date).
b. agree to take an antidepressant medication regularly by (date).
c. initiate social interaction with another person daily by (date).
d. identify two personal behaviors that alienate others by (date).
ANS: A
Low self-esteem is reflected by making consistently negative statements about self and selfworth. Replacing negative cognitions with more realistic appraisals of self is an appropriate
intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis.
Outcomes are best when framed positively; identifying two personal behaviors that might
alienate others is a negative concept.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-27, 53 (Table 14-2) | Page 14-16 (Case Study and Nursing Care Plan) | Page 274
TOP: Nursing Process: Outcomes Identification
MSC: Client Needs: Psychosocial Integrity
3. A patient diagnosed with major depressive disorder says, ―No one cares about me anymore. I‘m
not worth anything.‖ Today the patient is wearing a new shirt and has neat, clean hair. Which
remark by the nurse supports building a positive self-esteem for this patient? a. ―You look nice
this morning.‖
b. ―You‘re wearing a new shirt.‖
c. ―I like the shirt you are wearing.‖
d. ―You must be feeling better today.‖
ANS: B
Patients with depression usually see the negative side of things. The meaning of compliments
may be altered to ―I didn‘t look nice yesterday‖ or ―They didn‘t like my other shirt.‖ Neutral
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
comments such as making an observation avoid negative interpretations. Saying, ―You look
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
nice‖ or ―I like your shirt‖ gives approval (nontherapeutic techniques). Saying ―You must be
feeling better today‖ is an assumption, which is nontherapeutic.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 14-53 (Table 14-2) | Page 14-16 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. An adult diagnosed with major depressive disorder was treated with medication and cognitive-
behavioral therapy. The patient now recognizes how passivity contributed to the depression.
Which intervention should the nurse suggest? a. Social skills training
b. Relaxation training classes
c. Desensitization techniques
d. Use of complementary therapy
ANS: A
Social skills training is helpful in treating and preventing the recurrence of depression.
Training focuses on assertiveness and coping skills that lead to positive reinforcement from
others and development of a patient‘s support system. Use of complementary therapy refers to
adjunctive therapies such as herbals, which would be less helpful than social skills training.
Assertiveness would be of greater value than relaxation training because passivity was a
concern. Desensitization is used in treatment of phobias.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 14-16 (Case Study and Nursing Care Plan), 43
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
5. Priority interventions for a patient diagnosed with major depressive disorder and feelings of
worthlessness should include
a. distracting the patient from self-absorption.
b. careful unobtrusive observation around the clock.
c. allowing the patient to spend long periods alone in meditation.
d. opportunities to assume a leadership role in the therapeutic milieu.
ANS: B
Approximately two-thirds of people with depression contemplate suicide. Patients with
depressive disorder who exhibit feelings of worthlessness are at higher risk. Regular planned
observations of the patient diagnosed with depression may prevent a suicide attempt on the
unit.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-5 (DSM 5 Criteria), 53 (Table 14-2) | Page 14-16 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Planning MSC: Client Needs: Safe, Effective Care Environment
6. When counseling patients diagnosed with major depressive disorder, an advanced practice nurse
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will address the negative thought patterns by using a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive-behavioral therapy.
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d. alternative and complementary therapies.
ANS: C
Cognitive-behavioral therapy attempts to alter the patient‘s dysfunctional beliefs by focusing
on positive outcomes rather than negative attributions. The patient is also taught the
connection between thoughts and resultant feelings. Research shows that cognitive-behavioral
therapy involves the formation of new connections between nerve cells in the brain and that it
is at least as effective as medication. Evidence is not present to support superior outcomes for
the other psychotherapeutic modalities mentioned.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 14-43
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
7. A patient says to the nurse, ―My life doesn‘t have any happiness in it anymore. I once enjoyed
holidays, but now they‘re just another day.‖ The nurse documents this report as an example of a.
dysthymia.
b. anhedonia.
c. euphoria.
d. anergia.
ANS: B
Anhedonia is a common finding in many types of depression. It refers to feelings of a loss of
pleasure in formerly pleasurable activities. Dysthymia is a diagnosis. Euphoria refers to an
elated mood. Anergia means ―without energy.‖
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 14-7
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial
Integrity
8. A patient diagnosed with major depressive disorder began taking a tricyclic antidepressant 1
week ago. Today the patient says, ―I don‘t think I can keep taking these pills. They make me so
dizzy, especially when I stand up.‖ The nurse will
a. limit the patient‘s activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
c. teach the patient strategies to manage postural hypotension.
d. update the patient‘s mental status examination.
ANS: C
Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of
therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the
patient to stay well hydrated and rise slowly. Knowing this information may convince the
patient to continue the medication. Activity is an important aspect of the patient‘s treatment
plan and should not be limited to activities that can be done in a sitting position. Withholding
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Health Nursing A Clinical 9th Edition by Margaret Jordan
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the drug, forcing oral fluids, and notifying the health care provider are unnecessary actions.
Independent nursing action is called for. Updating a mental status examination is unnecessary.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-35, 60 (Table 14-6), 73 (Box 14-5)
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity
9.
A patient diagnosed with major depressive disorder is receiving imipramine 200 mg qhs.
Which assessment finding would prompt the nurse to collaborate with the health care provider
regarding potentially hazardous side effects of this drug? a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention
ANS: D
All the side effects mentioned are the result of the anticholinergic effects of the drug. Only
urinary retention and severe constipation warrant immediate medical attention. Dry mouth,
blurred vision, and nasal congestion may be less troublesome as therapy continues.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 14-34, 60 (Table 14-6) | Page 14-73 (Box 14-5)
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
10. A patient diagnosed with major depressive disorder tells the nurse, ―Bad things that happen are
always my fault.‖ Which response by the nurse will best assist the patient to reframe this
overgeneralization?
a. ―I really doubt that one person can be blamed for all the bad things that happen.‖
b. ―Let‘s look at one bad thing that happened to see if another explanation exists.‖
c. ―You are being extremely hard on yourself. Try to have a positive focus.‖
d. ―Are you saying that you don‘t have any good things happen?‖
ANS: B
By questioning a faulty assumption, the nurse can help the patient look at the premise more
objectively and reframe it as a more accurate representation of fact. The incorrect responses
cast doubt but do not require the patient to evaluate the statement.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-27, 57 (Table 14-4)
TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
11. A nurse worked with a patient diagnosed with major depressive disorder, severe withdrawal,
and psychomotor retardation. After 3 weeks, the patient did not improve. The nurse is most at
risk for feelings of
a. guilt and despair.
b. over-involvement.
c. interest and pleasure.
d. ineffectiveness and frustration.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
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ANS: D
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Nurses may have expectations for self and patients that are not wholly realistic, especially
regarding the patient‘s progress toward health. Unmet expectations result in feelings of
ineffectiveness, anger, or frustration. Nurses rarely become over-involved with patients with
depression because of the patient‘s resistance. Guilt and despair might be seen when the nurse
experiences the patient‘s feelings because of empathy. Interest is possible, but not the most
likely result.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 14-16 (Case Study and Nursing Care Plan), 25
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
12. A patient diagnosed with depressive disorder begins selective serotonin reuptake inhibitor
(SSRI) antidepressant therapy. The nurse should provide information to the patient and family
about
a. restricting sodium intake to 1 gram daily.
b. minimizing exposure to bright sunlight.
c. reporting increased suicidal thoughts.
d. maintaining a tyramine-free diet.
ANS: C
Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant
therapy; thus, close monitoring is necessary. Avoiding exposure to bright sunlight and
restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine
oxidase inhibitor (MAOI) therapy.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-25, 32, 72 (Box 14-4)
TOP: Nursing Process: Implementation MSC:
Client Needs: Physiological Integrity
13. A nurse taught a patient about a tyramine-restricted diet. Which menu selection would the nurse
approve?
a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
b. Mashed potatoes, ground beef patty, corn, green beans, apple pie
c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
ANS: B
The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain
little or no tyramine. Fresh ground beef and apple pie are safe. The other meals contain
various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe
bananas (banana bread), sausages/hot dogs, smoked meat (ham), cheddar cheese, yeast,
caffeine drinks, and chocolate.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-37, 60 (Table 14-6), 66 (Table 14-7)
TOP: Nursing Process: Evaluation MSC:
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
Client Needs: Physiological Integrity
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14. What is the focus of priority nursing interventions for the period immediately after
electroconvulsive therapy (ECT) treatment? a. Nutrition and hydration
b. Supporting physiological stability
c. Reducing disorientation and confusion
d. Assisting the patient to identify and test negative thoughts
ANS: B
During the immediate posttreatment period, the patient is recovering from general anesthesia;
hence, the priority need is to establish and support physiological stability. Reducing
disorientation and confusion is an acceptable intervention but not the priority. Assisting the
patient in identifying and testing negative thoughts is inappropriate in the immediate
posttreatment period because the patient may be confused.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 14-36 TOP:
Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
15. A nurse provided medication education for a patient diagnosed with major depressive disorder
who began a new prescription for phenelzine (Nardil). Which behavior indicates effective
learning? The patient
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. can identify foods with high selenium content that should be avoided.
d. confers with a pharmacist when selecting over-the-counter medications.
ANS: D
Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that
must be avoided when the patient takes MAOI antidepressants. Medications for colds,
allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine
may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need
for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyraminecontaining foods, not selenium, to produce dangerously high blood pressure.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-36, 60 (Table 14-6), 66 (Table 14-7)
TOP: Nursing Process: Evaluation MSC:
Client Needs: Physiological Integrity
16. Major depressive disorder resulted after a patient‘s employment was terminated. The patient
now says to the nurse, ―I‘m not worth the time you spend with me. I am the most useless
person in the world.‖ Which nursing diagnosis applies? a. Powerlessness
b. Defensive coping
c. Situational low self-esteem d. Disturbed personal identity
ANS: C
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The patient‘s statements express feelings of worthlessness and most clearly relate to the
nursing diagnosis of situational low self-esteem. Insufficient information exists to lead to
other diagnoses.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-16(Case Study and Nursing Care Plan), 53 (Table 14-2)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
17. A patient diagnosed with major depressive disorder does not interact with others except when
addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance
and support for the patient. Which communication technique will be effective? a. Make
observations.
b. Ask the patient direct questions.
c. Phrase questions to require yes or no answers.
d. Frequently reassure the patient to reduce guilt feelings.
ANS: A
Making observations about neutral topics draws the patient into the reality around him or her
but places no burdensome expectations for answers on the patient. Acceptance and support are
shown by the nurse‘s presence. Direct questions may make the patient feel that the encounter
is an interrogation. Open-ended questions are preferable if the patient is able to participate in
dialogue. Platitudes are never acceptable. They minimize patient feelings and can increase
feelings of worthlessness.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 14-56 (Table 14-3) TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
18. A patient being treated for depression has taken sertraline daily for a year. The patient calls the
clinic nurse and says, ―I stopped taking my antidepressant 2 days ago. Now I am having
nausea, nervous feelings, and I can‘t sleep.‖ The nurse will advise the patient to: a. ―Go to the
nearest emergency department immediately.‖
b. ―Do not to be alarmed. Take two aspirin and drink plenty of fluids.‖
c. ―Take a dose of your antidepressant now and come to the clinic to see the health care
provider.‖
d. ―Resume taking your antidepressants for 2 more weeks and then discontinue them
again.‖
ANS: C
The patient has symptoms associated with abrupt withdrawal of the antidepressant. Taking a
dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the
patient to discuss the advisability of going off the medication and to be given a gradual
withdrawal schedule if discontinuation is the decision. This situation is not a medical
emergency, although it calls for medical advice. Resuming taking the antidepressant for 2
more weeks and then discontinuing again would produce the same symptoms the patient is
experiencing.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Pages 14-60 (Table
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14-6), 72 (Box 14-4)
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity
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19. Which documentation for a patient diagnosed with major depressive disorder indicates the
treatment plan was effective?
a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
b. Slept 10 hours uninterrupted. Attended craft group; stated ―project was a failure, just
like me.‖
c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance.
Weight loss of 1 pound.
d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, ―I
feel tired all the time.‖
ANS: A
Sleeping 6 hours, participating with a group, and anticipating an event are all positive findings
that suggest effectiveness of the plan of care. All the other options show at least one negative
finding.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 14-16 (Case Study and Nursing Care Plan), 26, 44
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
20. A patient was diagnosed with seasonal affective disorder (SAD). During which month would
this patient‘s symptoms be most acute? a. January
b. April
c. June
d. September
ANS: A
The days are short in January, so the patient would have the least exposure to sunlight. SAD is
associated with disturbances in circadian rhythm. Days are longer in spring, summer, and fall.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 14-42
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
21. A patient diagnosed with major depressive disorder repeatedly tells staff, ―I have cancer. It‘s
my punishment for being a bad person.‖ Diagnostic tests reveal no cancer. Select the priority
nursing diagnosis.
a. Powerlessness
b. Risk for suicide
c. Stress overload
d. Spiritual distress
ANS: B
A patient diagnosed with major depressive disorder who feels so worthless as to believe
cancer is deserved is at risk for suicide. Safety concerns take priority over the other diagnoses
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listed.
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PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 14-8, 16 (Case Study and Nursing Care Plan), 53 (Table 14-2)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
22. A patient diagnosed with major depressive disorder refuses solid foods. In order to meet
nutritional needs, which beverage will the nurse offer to this patient? a.
Tomato juice
b. Orange juice
c. Hot tea
d. Milk
ANS: D
Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk
is fortified with vitamins.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 14-57 (Table 14-4) TOP: Nursing Process: Implementation MSC: Client
Needs: Physiological Integrity
23. During a psychiatric assessment, the nurse observes a patient‘s facial expression is without
emotion. The patient says, ―Life feels so hopeless to me. I‘ve been feeling sad for several
months.‖ How will the nurse document the patient‘s affect and mood? a. Affect depressed;
mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent.
ANS: B
Mood refers to a person‘s self-reported emotional feeling state. Affect is the emotional feeling
state that is outwardly observable by others. When there is no evidence of emotion in a
person‘s expression, the affect is flat.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-21, 22
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
24. A disheveled patient in the acute phase of major depressive disorder is withdrawn, has
psychomotor retardation, and has not showered for several days. The nurse will a. bring up the
issue at the community meeting.
b. calmly tell the patient, ―You must bathe daily.‖
c. make observations about the patient‘s poor personal hygiene.
d. firmly and neutrally assist the patient with showering.
ANS: D
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When patients are unable to perform self-care activities, staff must assist them rather than
ignore the issue. Better grooming increases self-esteem. The patient needs assistance, not
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simply making an observation. Calmly telling the patient to bathe daily and bringing up the
issue at a community meeting are punitive.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-53 (Table 14-2), 58 (Table 14-5) | Page 14-16 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
25. A patient diagnosed with major depressive disorder began taking escitalopram 5 days ago. The
patient now says, ―This medicine isn‘t working.‖ The nurse‘s best intervention would be to
a. discuss with the health care provider the need to increase the dose.
b. reassure the patient that the medication will be effective soon.
c. explain the time lag before antidepressants relieve symptoms.
d. critically assess the patient for symptoms of improvement.
ANS: C
Escitalopram is an SSRI antidepressant. One to three weeks of treatment is usually necessary
before symptom relief occurs. This information is important to share with patients.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-32, 60 (Table 14-6) | Page 14-72 (Box 14-4)
TOP: Nursing Process: Implementation
MSC: Client Needs: Physiological Integrity
26. A patient is experiencing psychomotor agitation associated with major depressive disorder.
Which observation would the nurse associate with this symptom? The patient a. paces
aimlessly around the room.
b. asks the nurse to repeat instructions.
c. complains of prickly skin sensations.
d. demonstrates slowed verbal responses.
ANS: A
Psychomotor agitation may be evidenced by constant pacing and wringing of hands. Slowed
movements and responses are aspects of psychomotor retardation. Complaints of the unusual
skin sensations may represent a delusion or hallucination. Asking the nurse to repeat
instructions indicates difficulty with concentration.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 14-8,
16 (Case Study and Nursing Care Plan), 21
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
27. A patient diagnosed with major depressive disorder received six ECT sessions and aggressive
doses of antidepressant medication. The patient owns a small business and was counseled not
to make major decisions for a month. Select the correct rationale for this counseling. a.
Antidepressant medications alter catecholamine levels, which impairs decision-making
abilities.
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b. Antidepressant medications may cause confusion related to limitation of tyramine in the
diet.
c. Temporary memory impairments and confusion may occur with ECT.
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d. The patient needs time to readjust to a pressured work schedule.
ANS: C
Recent memory impairment and/or confusion may be present during and for a short time after
ECT. An inappropriate business decision might be made because of forgotten important
details. The rationales are untrue statements in the incorrect responses. The patient needing
time to reorient to a pressured work schedule is less relevant than the correct rationale.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 14-39, 40
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
28. A nurse instructs a patient taking a medication that inhibits the action of monoamine oxidase
(MAO) to avoid certain foods and drugs because of the risk of a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock.
ANS: B
Patients taking MAO-inhibiting drugs must be on a tyramine-free diet to prevent hypertensive
crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and in high levels
produces intense vasoconstriction, resulting in elevated blood pressure.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 14-36, 60 (Table 14-6), 68 (Table 14-8), 75 (Box 14-7)
TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
29. Transcranial Magnetic Stimulation (TCM) is scheduled for a patient diagnosed with major
depressive disorder. Which comment by the patient indicates teaching about the procedure was
effective?
a. ―They will put me to sleep during the procedure so I won‘t know what is happening.‖
b. ―I might be a little dizzy or have a mild headache after each procedure.‖
c. ―I will be unable to care for my children for about 2 months.‖
d. ―I will avoid eating foods that contain tyramine.‖
ANS: B
TCM treatments take about 30 minutes. Treatments are usually 5 days a week. Patients are
awake and alert during the procedure. After the procedure, patients may experience a
headache and lightheadedness. No neurological deficits or memory problems have been
noted. The patient will be able to care for children.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 14-40 TOP:
Nursing Process: Evaluation
MSC: Client Needs: Physiological Integrity
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
MULTIPLE RESPONSE
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
1. The admission note indicates a patient diagnosed with major depressive disorder has anergia
and anhedonia. For which measures should the nurse plan? (Select all that apply.) a.
Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardation
ANS: C, D, E
Anergia refers to a lack of energy. Anhedonia refers to the inability to find pleasure or
meaning in life; thus, planning should include measures to accommodate psychomotor
retardation, assist with activities of daily living, and instill hopefulness. Anergia is lack of
energy, not excessive energy. Anhedonia does not necessarily imply the presence of guilty
ruminations.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 14-7, 16 (Case Study and Nursing Care Plan), 20
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
2. A nurse caring for a patient diagnosed with major depressive disorder reads in the patient‘s
medical record, ―This patient shows vegetative signs of depression.‖ Which nursing diagnoses
most clearly relate to this documentation? (Select all that apply.) a. Imbalanced nutrition: less
than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia
ANS: A, C, D, F
Vegetative signs of depression are alterations in body processes necessary to support life and
growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more
closely related to vegetative signs than diagnoses associated with feelings about self.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Pages
14-53(Table 14-2), 58 (Table 14-5)
TOP: Nursing
Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
3. A patient diagnosed with major depressive disorder shows vegetative signs of depression.
Which nursing actions should be implemented? (Select all that apply.) a. Offer laxatives if
needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
d. Eliminate all daily caffeine intake.
e. Restrict intake of processed foods.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
ANS: A, B, C
The correct options promote a normal elimination pattern. Although excessive intake of
stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may
provide useful stimulation. No indication exists that processed foods should be restricted.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 14-21, 23, 27, 53 (Table 14-2), 58 (Table 14-5)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
4. A patient being treated with paroxetine 50 mg po daily reports to the clinic nurse, ―I took a
few extra tablets earlier today and now I feel bad.‖ Which assessments are most critical?
(Select all that apply.) a. Vital signs
b. Urinary frequency
c. Psychomotor retardation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness
ANS: A, D, E
The patient is taking the maximum dose of this SSRI and has ingested an additional unknown
amount of the drug. Serotonin syndrome must be considered. Symptoms include abdominal
pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity,
and muscle spasms. Serotonin syndrome may progress to a full medical emergency if not
treated early. The patient may have urinary retention, but frequency would not be expected.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Pages 14-33,
34, 60 (Table 14-6), 71 (Box 14-3)
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
Chapter 15: Anxiety and Obsessive-Compulsive Disorders
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1. A nurse wants to teach alternative coping strategies to a patient experiencing severe anxiety.
Which action should the nurse perform first?
a. Verify the patient‘s learning style.
b. Lower the patient‘s current anxiety.
c. Create outcomes and a teaching plan.
d. Assess how the patient uses defense mechanisms.
ANS: B
A patient experiencing severe anxiety has a markedly narrowed perceptual field and difficulty
attending to events in the environment. A patient experiencing severe anxiety will not learn
readily. Determining preferred modes of learning, devising outcomes, and constructing
teaching plans are relevant to the task but are not the priority measure. The nurse has already
assessed the patient‘s anxiety level. Use of defense mechanisms does not apply.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 15-4, 5, 64 (Table 15-1)
TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
2. A woman is 5'7", 160 lbs. and wears a size 8 shoe. She says, ―My feet are huge. I‘ve asked three
orthopedists to surgically reduce my feet.‖ This person tries to buy shoes to make her feet look
smaller and, in social settings, conceals both feet under a table or chair. Which health problem is
likely?
a. Social anxiety disorder
b. Body dysmorphic disorder
c. Separation anxiety disorder
d. Obsessive-compulsive disorder due to a medical condition
ANS: B
Body dysmorphic disorder refers to a preoccupation with an imagined defect in appearance in
a normal-appearing person. The patient‘s feet are proportional to the rest of the body. In
obsessive-compulsive or related disorder due to a medical condition, the individual‘s
symptoms of obsessions and compulsions are a direct physiological result of a medical
condition. Social anxiety disorder, also called social phobia, is characterized by severe anxiety
or fear provoked by exposure to a social or a performance situation that will be evaluated
negatively by others. People with separation anxiety disorder exhibit developmentally
inappropriate levels of concern over being away from a significant other.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-28, 29
TOP: Nursing Process: Assessment
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
MSC: Client Needs: Psychosocial Integrity
3.
A patient experiencing moderate anxiety says, ―I feel undone.‖ An appropriate response for the
nurse would be:
a. ―What would you like me to do to help you?‖
b. ―Why do you suppose you are feeling anxious?‖
c. ―I‘m not sure I understand. Give me an example.‖
d. ―You must get your feelings under control before we can continue.‖
ANS: C
Increased anxiety results in scattered thoughts and an inability to articulate clearly. Clarifying
helps the patient identify thoughts and feelings. Asking the patient why he or she feels
anxious is nontherapeutic; the patient likely does not have an answer. The patient may be
unable to determine what he or she would like the nurse to do in order to help. Telling the
patient to get his or her feelings under control is a directive the patient is probably unable to
accomplish.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-39, 40, 83 (Table 15-9) TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
4.
A patient fearfully runs from chair to chair crying, ―They‘re coming! They‘re coming!‖ The
patient does not follow the staff‘s directions or respond to verbal interventions. The initial
nursing intervention of highest priority is to a. provide for the patient‘s safety.
b. encourage clarification of feelings.
c. respect the patient‘s personal space.
d. offer an outlet for the patient‘s energy.
ANS: A
Safety is of highest priority because the patient experiencing panic is at high risk for selfinjury related to increased non-goal-directed motor activity, distorted perceptions, and
disordered thoughts. Offering an outlet for the patient‘s energy can occur when the current
panic level subsides. Respecting the patient‘s personal space is a lower priority than safety.
Clarification of feelings cannot take place until the level of anxiety is lowered.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 15-18, 40, 72 (Table 15-4) TOP: Nursing Process: Planning MSC:
Client Needs: Safe, Effective Care Environment
5.
A patient fearfully runs from chair to chair crying, ―They‘re coming! They‘re coming!‖ The
patient does not follow the staff‘s directions or respond to verbal interventions. Which nursing
diagnosis has the highest priority? a. Fear
b. Risk for injury
c. Self-care deficit
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d. Disturbed thought processes
ANS: B
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A patient experiencing panic-level anxiety is at high risk for injury related to increased nongoal-directed motor activity, distorted perceptions, and disordered thoughts. Data are not
present to support a nursing diagnosis of self-care deficit or disturbed thought processes. The
patient may have fear, but the risk for injury has a higher priority.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 15-40, 81 (Table 15-8), 85 (Table 15-10)
TOP:
Nursing Process: Diagnosis/Analysis
MSC: Client Needs:
Safe, Effective Care Environment
6.
A patient checks and rechecks electrical cords related to an obsessive thought that the house
may burn down. The nurse and patient explore the likelihood of an actual fire. The patient states
this event is not likely. This counseling demonstrates principles of a. flooding.
b. desensitization.
c. relaxation technique.
d. cognitive restructuring.
ANS: D
Cognitive restructuring involves the patient in testing automatic thoughts and drawing new
conclusions. Desensitization involves graduated exposure to a feared object. Relaxation
training teaches the patient to produce the opposite of the stress response. Flooding exposes
the patient to a large amount of an undesirable stimulus in an effort to extinguish the anxiety
response.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-51, 52, 72 (Table 15-4) TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
7.
A patient undergoing diagnostic tests says, ―Nothing is wrong with me except a stubborn chest
cold.‖ The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily
fatigued. Which defense mechanism is the patient using? a. Displacement
b. Regression
c. Projection
d. Denial
ANS: D
Denial is an unconscious blocking of threatening or painful information or feelings.
Regression involves using behaviors appropriate at an earlier stage of psychosexual
development. Displacement shifts feelings to a more neutral person or object. Projection
attributes one‘s own unacceptable thoughts or feelings to another.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
8.
A patient with an abdominal mass is scheduled for a biopsy. The patient has difficulty
understanding the nurse‘s comments and asks, ―What do you mean? What are they going to
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
do?‖ Assessment findings include tremulous voice, respirations 28, and pulse 110. What is the
patient‘s level of anxiety? a. Mild
b. Moderate
c. Severe
d. Panic
ANS: B
Moderate anxiety causes the individual to grasp less information and reduces problem-solving
ability to a less-than-optimal level. Mild anxiety heightens attention and enhances problem
solving. Severe anxiety causes great reduction in the perceptual field. Panic-level anxiety
results in disorganized behavior.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-4, 5, 64 (Table 15-1)
TOP: Nursing Process: Assessment MSC:
Client Needs: Physiological Integrity
9.
A patient preparing for surgery has moderate anxiety and is unable to understand preoperative
information. Which nursing intervention is most appropriate?
a. Reassure the patient that all nurses are skilled in providing postoperative care.
b. Present the information again in a calm manner using simple language.
c. Tell the patient that staff is prepared to promote recovery.
d. Encourage the patient to express feelings to family.
ANS: B
Giving information in a calm, simple manner will help the patient grasp the important facts.
Introducing extraneous topics as described in the distracters will further scatter the patient‘s
attention.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-39, 40 (Table 15-9)
TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
10. A patient is experiencing moderate anxiety. The nurse encourages the patient to talk about
feelings and concerns. What is the rationale for this intervention? a. Offering hope allays and
defuses the patient‘s anxiety.
b. Concerns stated aloud become less overwhelming and help problem solving begin.
c. Anxiety is reduced by focusing on and validating what is occurring in the
environment.
d. Encouraging patients to explore alternatives increases the sense of control and lessens
anxiety.
ANS: B
All principles listed are valid, but the only rationale directly related to the intervention of
assisting the patient to talk about feelings and concerns is the one that states that concerns
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
spoken aloud become less overwhelming and help problem solving begin.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
REF: Pages 15-39, 40, 83 (Table 15-9)
Client Needs: Psychosocial Integrity
TOP: Nursing Process: Implementation MSC:
11. A nurse assesses a patient with a tentative diagnosis of generalized anxiety disorder. Which
question would be most appropriate for the nurse to ask?
a. ―Have you been a victim of a crime or seen someone badly injured or killed?‖
b. ―Do you feel especially uncomfortable in social situations involving people?‖
c. ―Do you repeatedly do certain things over and over again?‖
d. ―Do you find it difficult to control your worrying?‖
ANS: D
Patients with generalized anxiety disorder frequently engage in excessive worrying. They are
less likely to engage in ritualistic behavior, fear social situations, or have been involved in a
highly traumatic event.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-22, 23, 44
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
12. A patient in the emergency department shows disorganized behavior and incoherence after a
friend suggested a homosexual encounter. In which room should the nurse place the patient? a.
An interview room furnished with a desk and two chairs
b. A small, empty storage room with no windows or furniture
c. A room with an examining table, instrument cabinets, desk, and chair
d. The nurse‘s office, furnished with chairs, files, magazines, and bookcases
ANS: A
Individuals experiencing severe to panic-level anxiety require a safe environment that is quiet,
nonstimulating, structured, and simple. A room with a desk and two chairs provides
simplicity, few objects with which the patient could cause self-harm, and a small floor space
in which the patient can move about. A small, empty storage room without windows or
furniture would feel like a jail cell. The nurse‘s office or a room with an examining table and
instrument cabinets may be over-stimulating and unsafe.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-6 (Case Study and Nursing Care Plan), 64 (Table 15-1), 72 (Table 15-4), 85 (Table
15-10) TOP:
Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
13. A person has minor physical injuries after an auto accident. The person is unable to focus and
says, ―I feel like something awful is going to happen.‖ This person has nausea, dizziness,
tachycardia, and hyperventilation. What is the person‘s level of anxiety? a. Mild
b. Moderate
c. Severe
d. Panic
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ANS: C
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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The person whose anxiety is severe is unable to solve problems and may have a poor grasp of
what is happening in the environment. Somatic symptoms such as those described are usually
present. The individual with mild anxiety is only mildly uncomfortable and may even find his
or her performance enhanced. The individual with moderate anxiety grasps less information
about a situation and has some difficulty with problem solving. The individual in panic will
demonstrate markedly disturbed behavior and may lose touch with reality.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-5, 64 (Table 15-1)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
14. Two staff nurses applied for a charge nurse position. After the promotion was announced, the
nurse who was not promoted said, ―The nurse manager had a headache the day I was
interviewed.‖ Which defense mechanism is evident?
a. Introjection
b. Conversion
c. Projection
d. Splitting
ANS: C
Projection is the hallmark of blaming, scapegoating, prejudicial thinking, and stigmatizing
others. Conversion involves the unconscious transformation of anxiety into a physical
symptom. Introjection involves intense, unconscious identification with another person.
Splitting is the inability to integrate the positive and negative qualities of oneself or others
into a cohesive image.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
15. A patient tells a nurse, ―My best friend is a perfect person. She is kind, considerate, good-
looking, and successful with every task. I could have been like her if I had the opportunities,
luck, and money she‘s had.‖ This patient is demonstrating a. denial.
b. projection.
c. rationalization.
d. compensation.
ANS: C
Rationalization consists of justifying illogical or unreasonable ideas, actions, or feelings by
developing acceptable explanations that satisfy the teller as well as the listener. Denial is an
unconscious process that would call for the nurse to ignore the existence of the situation.
Projection operates unconsciously and would result in blaming behavior. Compensation
would result in the nurse unconsciously attempting to make up for a perceived weakness by
emphasizing a strong point.
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PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
REF: Pages 15-11, 12, 66 (Table 15-2)
Client Needs: Psychosocial Integrity
TOP: Nursing Process: Assessment MSC:
16. A patient experiences a sudden episode of severe anxiety. Of these medications in the patient‘s
medical record, which is most appropriate to give as a prn anxiolytic? a. buspirone
b. lorazepam
c. amitriptyline
d. desipramine
ANS: B
Lorazepam is a benzodiazepine used to treat anxiety. It may be given as a prn medication.
Buspirone is long acting and is not useful as a prn drug. Amitriptyline and desipramine are
tricyclic antidepressants and considered second- or third-line agents.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-45, 46, 88 (Table 15-11) TOP: Nursing Process: Implementation MSC:
Client Needs: Physiological Integrity
17. Two staff nurses applied for promotion to nurse manager. The nurse not promoted initially had
feelings of loss but then became supportive of the new manager by helping make the transition
smooth and encouraging others. Which term best describes the nurse‘s response? a. Altruism
b. Suppression
c. Intellectualization
d. Reaction formation
ANS: A
Altruism is the mechanism by which an individual deals with emotional conflict by meeting
the needs of others and receiving gratification vicariously or from the responses of others. The
nurse‘s reaction is conscious rather than unconscious. There is no evidence of suppression.
Intellectualization is a process in which events are analyzed based on remote, cold facts and
without passion, rather than incorporating feeling and emotion into the processing. Reaction
formation is when unacceptable feelings or behaviors are controlled and kept out of
awareness by developing the opposite behavior or emotion.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-12, 66 (Table 15-2)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
18. A person who feels unattractive repeatedly says, ―Although I‘m not beautiful, I am smart.‖
This is an example of a. repression.
b. devaluation.
c. identification.
d. compensation.
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ANS: D
Compensation is an unconscious process that allows us to make up for deficits in one area by
excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or
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feeling out of awareness. Identification is an unconscious mechanism calling for imitation of
mannerisms or behaviors of another. Devaluation occurs when the individual attributes
negative qualities to self or others.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
19. A person speaking about a rival for a significant other‘s affection says in an emotional, syrupy
voice, ―What a lovely person. That‘s someone I simply adore.‖ The individual is
demonstrating
a. reaction formation.
b. repression.
c. projection.
d. denial.
ANS: A
Reaction formation is an unconscious mechanism that keeps unacceptable feelings out of
awareness by using the opposite behavior. Instead of expressing hatred for the other person,
the individual gives praise. Denial operates unconsciously to allow an anxiety-producing idea,
feeling, or situation to be ignored. Projection involves unconsciously disowning an
unacceptable idea, feeling, or behavior by attributing it to another. Repression involves
unconsciously placing an idea, feeling, or event out of awareness.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-12, 66 (Table 15-2)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
20. An individual experiences sexual dysfunction and blames it on a partner by calling the person
unattractive and unromantic. Which defense mechanism is evident? a. Rationalization
b. Compensation
c. Introjection
d. Regression
ANS: A
Rationalization involves unconsciously making excuses for one‘s behavior, inadequacies, or
feelings. Regression involves the unconscious use of a behavior from an earlier stage of
emotional development. Compensation involves making up for deficits in one area by
excelling in another area. Introjection is an unconscious, intense identification with another
person.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-11, 12, 66 (Table 15-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
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21. A student says, ―Before taking a test, I feel very alert and a little restless.‖ The nurse can
correctly assess the student‘s experience as a. culturally influenced.
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b. displacement.
c. trait anxiety.
d. mild anxiety.
ANS: D
Mild anxiety is rarely obstructive to the task at hand. It may be helpful to the patient because
it promotes study and increases awareness of the nuances of questions. The incorrect
responses have different symptoms.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 15-4, 64 (Table 15-1)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
22. A student says, ―Before taking a test, I feel very alert and a little restless.‖ Which nursing
intervention is most appropriate to assist the student?
a. Explain that the symptoms result from mild anxiety and discuss the helpful aspects.
b. Advise the student to discuss this experience with a health care provider.
c. Encourage the student to begin antioxidant vitamin supplements.
d. Listen attentively, using silence in a therapeutic way.
ANS: A
Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case,
the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss
the experience with a health care provider implies that the patient has a serious problem.
Listening without comment will do no harm but deprives the patient of health teaching.
Antioxidant vitamin supplements are not useful in this scenario.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-4, 64 (Table 15-1) | Pages 15-39, 40 (Table 15-9)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
23. A cruel and abusive person often uses rationalization to explain the behavior. Which comment
demonstrates use of this defense mechanism? a. ―I don‘t know why I do mean things.‖
b. ―I have always had poor impulse control.‖
c. ―That person should not have provoked me.‖
d. ―I‘m really a coward who is afraid of being hurt.‖
ANS: C
Rationalization consists of justifying one‘s unacceptable behavior by developing explanations
that satisfy the teller and attempt to satisfy the listener. The abuser is suggesting that the abuse
is not his or her fault; it would not have occurred except for the provocation by the other
person. The distracters indicate some measure of acceptance of responsibility for the behavior.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
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REF: Pages 15-12, 66 (Table 15-2)
Client Needs: Psychosocial Integrity
TOP: Nursing Process: Assessment MSC:
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24. A patient experiencing panic suddenly began running and shouting, ―I‘m going to explode!‖
Select the nurse‘s best action.
a. Ask, ―I‘m not sure what you mean. Give me an example.‖
b. Capture the patient in a basket-hold to increase feelings of control.
c. Tell the patient, ―Stop running and take a deep breath. I will help you.‖
d. Assemble several staff members and say, ―We will take you to seclusion to help
you regain control.‖
ANS: C
Safety needs of the patient and other patients are a priority. Comments to the patient should be
simple, neutral, and give direction to help the patient regain control. Running after the patient
will increase the patient‘s anxiety. More than one staff member may be needed to provide
physical limits, but using seclusion or physically restraining the patient prematurely is
unjustified. Asking the patient to give an example would be futile; a patient in panic processes
information poorly.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-6 (Case Study and Nursing Care Plan), 64 (Table 15-1), 72 (Table 15-4), 85 (Table
15-10) TOP:
Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
25. A person who has been unable to leave home for more than a week because of severe anxiety
says, ―I know it does not make sense, but I just can‘t bring myself to leave my apartment
alone.‖ Which nursing intervention is appropriate?
a. Help the person use online video calls to provide interaction with others.
b. Advise the person to accept the situation and use a companion.
c. Ask the person to explain why the fear is so disabling.
d. Teach the person to use positive self-talk techniques.
ANS: D
Positive self-talk, a form of cognitive restructuring, replaces negative thoughts such as ―I
can‘t leave my apartment‖ with positive thoughts such as ―I can control my anxiety.‖ This
technique helps the patient gain mastery over the symptoms. The other options reinforce the
sick role.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-51, 72 (Table 15-4)
TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
26. A nurse assesses an individual who commonly experiences anxiety. Which comment by this
person indicates the possibility of obsessive-compulsive disorder? a. ―I check where my car
keys are eight times.‖
b. ―My legs often feel weak and spastic.‖
c. ―I‘m embarrassed to go out in public.‖
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d. ―I keep reliving a car accident.‖
ANS: A
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Recurring doubt (obsessive thinking) and the need to check (compulsive behavior) suggest
obsessive-compulsive disorder. The repetitive behavior is designed to decrease anxiety but
fails and must be repeated. Stating ―My legs feel weak most of the time‖ is more in keeping
with a somatic disorder. Being embarrassed to go out in public is associated with an avoidant
personality disorder. Reliving a traumatic event is associated with posttraumatic stress
disorder.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 15-25 to 27, 79 (Table 15-7) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
27. When alprazolam is prescribed for a patient who experiences acute anxiety, health teaching
should include instructions to a. report drowsiness.
b. eat a tyramine-free diet.
c. avoid alcoholic beverages.
d. adjust dose and frequency based on anxiety level.
ANS: C
Drinking alcohol or taking other anxiolytics along with the prescribed benzodiazepine should
be avoided because depressant effects of both drugs will be potentiated. Tyramine-free diets
are necessary only with monoamine oxidase inhibitors (MAOIs). Drowsiness is an expected
effect and needs to be reported only if it is excessive. Patients should be taught not to deviate
from the prescribed dose and schedule for administration.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-45, 46, 91 (Box 15-2)
TOP: Nursing Process: Planning MSC:
Client Needs: Physiological Integrity
28. The nurse assesses a patient who complains of loneliness and episodes of anxiety. Which
statement by the patient is mostly likely if this patient also has agoraphobia? a. ―I‘m sure I will
get over not wanting to leave home soon. It takes time.‖
b. ―Being afraid to go out seems ridiculous, but I can‘t go out the door.‖
c. ―My family says they like it now that I stay home most of the time.‖
d. ―When I have a good incentive to go out, I can do it.‖
ANS: B
Individuals who are agoraphobic generally acknowledge that the behavior is not constructive
and that they do not really like it. The symptom is ego dystonic. However, patients will state
they are unable to change the behavior. Agoraphobics are not optimistic about change. Most
families are dissatisfied when family members refuse to leave the house.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 15-20, 71 (Table 15-3) | Pages 15-38, 81 (Table 15-8)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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29. A patient diagnosed with obsessive-compulsive disorder has this nursing diagnosis: Anxiety
related to
as evidenced by inability to control compulsive cleaning. Which phrase
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correctly completes the etiological portion of the diagnosis? a. feelings of responsibility for the
health of family members
b. approval-seeking behavior from friends and family
c. persistent thoughts about bacteria, germs, and dirt
d. needs to avoid interactions with others
ANS: C
Many compulsive rituals accompany obsessive thoughts. The patient uses these rituals for
anxiety relief. Unfortunately, the anxiety relief is short lived, and the patient must frequently
repeat the ritual. The other options are unrelated to the dynamics of compulsive behavior.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 15-25
to 27, 79 (Table 15-7), 81 (Table 15-8)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
30. A patient performs ritualistic hand washing. Which action should the nurse implement to help
the patient develop more effective coping?
a. Allow the patient to set a hand-washing schedule.
b. Encourage the patient to participate in social activities.
c. Encourage the patient to discuss hand-washing routines.
d. Focus on the patient‘s symptoms rather than on the patient.
ANS: B
Because obsessive-compulsive patients become overly involved in the rituals, promotion of
involvement with other people and activities is necessary to improve coping. Daily activities
prevent constant focus on anxiety and symptoms. The other interventions focus on the
compulsive symptom.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-38, 81 (Table 15-8) | Pages 15-41, 89 (Box 15-1)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
31. For a patient experiencing panic, which nursing intervention should be implemented first? a.
Teach relaxation techniques.
b. Administer an anxiolytic medication.
c. Prepare to implement physical controls.
d. Provide calm, brief, directive communication.
ANS: D
Calm, brief, directive verbal interaction can help the patient gain control of overwhelming
feelings and impulses related to anxiety. Patients experiencing panic-level anxiety are unable
to focus on reality; thus, learning relaxation techniques is virtually impossible. Administering
anxiolytic medication should be considered if providing calm, brief, directive communication
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is ineffective. Although the patient is disorganized, violence may not be imminent, ruling out
the intervention of preparing for physical control until other less-restrictive measures are
proven ineffective.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-18, 72 (Table 15-4)
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
MULTIPLE RESPONSE
1. A child was placed in a foster home after being removed from abusive parents. The child is
apprehensive and overreacts to environmental stimuli. The foster parents ask the nurse how to
help the child. Which interventions should the nurse suggest? (Select all that apply.) a. Use a
calm manner and low voice.
b. Maintain simplicity in the environment.
c. Avoid repetition in what is said to the child.
d. Minimize opportunities for exercise and play.
e. Explain and reinforce reality to avoid distortions.
ANS: A, B, E
The child has moderate anxiety. A calm manner will calm the child. A simple, structured,
predictable environment is desirable to decrease anxiety provoking and reduce stimuli. Calm,
simple explanations that reinforce reality validate the environment. Repetition is often needed
when the individual is unable to concentrate because of elevated levels of anxiety.
Opportunities for play and exercise should be provided as avenues to reduce anxiety. Physical
movement helps channel and lower anxiety. Play helps by allowing the child to act out
concerns.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-39, 40 (Table 15-9) | Pages 15-41, 89 (Box 15-1)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. A nurse plans health teaching for a patient diagnosed with generalized anxiety disorder who
begins a new prescription for lorazepam. What information should be included? (Select all that
apply.)
a. Caution in use of machinery
b. Foods allowed on a tyramine-free diet
c. The importance of caffeine restriction
d. Avoidance of alcohol and other sedatives
e. Take the medication on an empty stomach
ANS: A, C, D
Caffeine is a central nervous system stimulant that acts as an antagonist to the benzodiazepine
lorazepam. Daily caffeine intake should be reduced to the amount contained in one cup of
coffee. Benzodiazepines are sedatives, thus the importance of exercising caution when driving
or using machinery and the importance of not using other central nervous system depressants
such as alcohol or sedatives to avoid potentiation. Benzodiazepines do not require a special
diet. Food will reduce gastric irritation from the medication.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
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REF: Pages 15-88 (Table 15-11), 91 (Box 15-2)
Needs: Physiological Integrity
TOP: Nursing Process: Planning MSC: Client
3. Which assessment questions would be most appropriate for the nurse to ask a patient with
possible obsessive-compulsive disorder? (Select all that apply.)
a. ―Are there certain social situations that cause you to feel especially uncomfortable?‖
b. ―Are there others in your family who must do things in a certain way to feel
comfortable?‖
c. ―Have you been a victim of a crime or seen someone badly injured or killed?‖
d. ―Is it difficult to keep certain thoughts out of your awareness?‖
e. ―Do you do certain things over and over again?‖
ANS: B, D, E
The correct questions refer to obsessive thinking and compulsive behaviors. There is likely a
genetic correlation to the disorder. The incorrect responses are more pertinent to a patient with
suspected posttraumatic stress disorder or with suspected social phobia.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-36, 37
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
4. The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses
most likely apply to this individual? (Select all that apply.) a. Ineffective home maintenance
b. Situational low self-esteem
c. Chronic low self-esteem
d. Disturbed body image
e. Risk for injury
ANS: A, C, E
Shame regarding the appearance of one‘s home is associated with hoarding. The behavior is
usually associated with chronic low self-esteem. Hoarding results in problems of home
maintenance, which may precipitate injury. The self-concept may be affected, but not body
image.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 15-29, 30, 38, 81 (Table 15-8)
TOP:
Nursing Process: Analysis/Diagnosis
MSC: Client Needs:
Psychosocial Integrity
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Chapter 16: Trauma, Stressor-Related, and Dissociative Disorders
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1. A nurse works with a patient diagnosed with posttraumatic stress disorder (PTSD) who has
frequent flashbacks as well as persistent symptoms of arousal. Which intervention should be
included in the plan of care?
a. Trigger flashbacks intentionally in order to help the patient learn to cope with them.
b. Explain that the physical symptoms are related to the psychological state.
c. Encourage repression of memories associated with the traumatic event.
d. Support ―numbing‖ as a temporary way to manage intolerable feelings.
ANS: B
Persons with PTSD often experience somatic symptoms or sympathetic nervous system
arousal that can be confusing and distressing. Explaining that these are the body‘s responses
to psychological trauma helps the patient understand how such symptoms are part of the
illness and something that will respond to treatment. This decreases powerlessness over the
symptoms and helps instill a sense of hope. It also helps the patient to understand how
relaxation, breathing exercises, and imagery can be helpful in symptom reduction. The goal of
treatment for PTSD is to come to terms with the event so treatment efforts would not include
repression of memories or numbing. Triggering flashbacks would increase patient distress.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-29, 32 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
2. Four teenagers died in an automobile accident. One week later, which behavior by the parents of
these teenagers most clearly demonstrates resilience? The parents who a. visit their teenager‘s
grave daily.
b. return immediately to employment.
c. discuss the accident within the family only.
d. create a scholarship fund at their child‘s high school.
ANS: D
Resilience refers to positive adaptation or the ability to maintain or regain mental health
despite adversity. Loss of a child is among the highest risk situations for maladaptive
grieving. The parents who create a scholarship fund are openly expressing their feelings and
memorializing their child. The other parents in this question are isolating themselves and/or
denying their feelings. Visiting the grave daily shows active continued mourning but is not as
strongly indicative of resilience as the correct response.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-17, 18, 32 (Case Study and Nursing Care Plan)
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TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3. After the sudden death of his wife, a man says, ―I can‘t live without her … she was my whole
life.‖ Select the nurse‘s most therapeutic reply.
a. ―Each day will get a little better.‖
b. ―Her death is a terrible loss for you.‖
c. ―It‘s important to recognize that she is no longer suffering.‖
d. ―Your friends will help you cope with this change in your life.‖
ANS: B
Adjustment disorders may be associated with grief. A statement that validates a bereaved
person‘s loss is more helpful than false reassurances and clichés. It signifies understanding.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-42, 43, 55
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
4. A woman just received notification that her husband died. She approaches the nurse who cared
for him during his last hours and says angrily, ―If you had given him your undivided attention, he
would still be alive.‖ How should the nurse analyze this behavior? a. The comment suggests
potential allegations of malpractice.
b. In some cultures, grief is expressed solely through anger.
c. Anger is an expected emotion in an adjustment disorder.
d. The patient had ambivalent feelings about her husband.
ANS: C
Symptoms of adjustment disorder run the gamut of all forms of distress including guilt,
depression, and anger. Anger may protect the bereaved from facing the devastating reality of
loss.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 16-42 TOP:
Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
5. A wife received news that her husband died of heart failure and called her family to come to the
hospital. She angrily tells the nurse who cared for him, ―He would still be alive if you had given
him your undivided attention.‖ Select the nurse‘s best intervention.
a. Say to the wife, ―I understand you are feeling upset. I will stay with you until your family
comes.‖
b. Say to the wife, ―Your husband‘s heart was so severely damaged that it could no longer
pump.‖
c. Say to the wife, ―I will call the health care provider to discuss this matter with you.‖
d. Hold the wife‘s hand in silence until the family arrives.
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ANS: A
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The nurse builds trust and shows compassion in the face of adjustment disorders. Therapeutic
responses provide comfort. The nurse should show patience and tact while offering sympathy
and warmth. The distracters are defensive, evasive, or placating.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-32 (Case Study and Nursing Care Plan), 42, 43, 55
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
6. A child drowned while swimming in a local lake 2 years ago. Which behavior indicates the
child‘s parents have adapted to their loss? The parents
a. visit their child‘s grave daily.
b. maintain their child‘s room as the child left it 2 years ago.
c. keep a place set for the dead child at the family dinner table.
d. throw flowers on the lake at each anniversary date of the accident.
ANS: D
Resilience refers to positive adaptation or the ability to maintain or regain mental health
despite adversity. Loss of a child is among the highest risk situations for an adjustment
disorder and maladaptive grieving. The parents who throw flowers on the lake on each
anniversary date of the accident are openly expressing their feelings. The other behaviors are
maladaptive because of isolating themselves and/or denying their feelings. After 2 years, the
frequency of visiting the grave should have decreased.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-17, 18, 32 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
7. A store clerk was killed during a robbery 2 weeks ago. His widow, who has a long history of
schizoaffective disorder, cries spontaneously when talking about his death. Select the nurse‘s
most therapeutic response.
a. ―Are you taking your medications the way they are prescribed?‖
b. ―This loss is harder to accept because of your mental illness. Do you think you should be
hospitalized?‖
c. ―I‘m worried about how much you are crying. Your grief over your husband‘s death has
gone on too long.‖
d. ―The unexpected death of your husband is very painful. I‘m glad you are able to
talk about your feelings.‖
ANS: D
The patient is expressing feelings related to the loss, and this is an expected and healthy
behavior. This patient is at risk for a maladaptive response because of the history of a serious
mental illness, but the nurse‘s priority intervention is to form a therapeutic alliance and
support the patient‘s expression of feelings. Crying at 2 weeks after his death is expected and
normal.
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PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 16-55 TOP:
Nursing Process: Implementation
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MSC: Client Needs: Psychosocial Integrity
8. Which scenario demonstrates a dissociative fugue?
a. After being caught in an extramarital affair, a man disappeared but then reappeared
months later with no memory of what occurred while he was missing.
b. A man is extremely anxious about his problems and sometimes experiences dazed periods
of several minutes passing without conscious awareness of them.
c. A woman finds unfamiliar clothes in her closet, is recognized when she goes to new
restaurants, and complains of ―blackouts‖ despite not drinking.
d. A woman reports that when she feels tired or stressed, it seems like her body is not
real and is somehow growing smaller.
ANS: A
The patient in a dissociative fugue state relocates and lacks recall of his life before the fugue
began. Often fugue states follow traumatic experiences and sometimes involve assuming a
new identity. Such persons at some point find themselves in their new surroundings, unable to
recall who they are or how they got there. A feeling of detachment from one‘s body or from
the external reality is an indication of depersonalization disorder. Losing track of several
minutes when highly anxious is not an indication of a dissociative disorder and is common in
states of elevated anxiety. Finding evidence of having bought clothes or gone to restaurants
without any explanation for these is suggestive of dissociative identity disorder, particularly
when periods are ―lost‖ to the patient (blackouts).
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 16-49
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
9.
The nurse who is counseling a patient with dissociative identity disorder should understand
that the assessment of highest priority is a. risk for self-harm.
b. cognitive function.
c. memory impairment.
d. condition of self-esteem.
ANS: A
Assessments that relate to patient safety take priority. Patients with dissociative disorders may
be at risk for suicide or self-mutilation, so the nurse must be alert for indicators of risk for
self-injury. The other options are important assessments but rank below safety. Treatment
motivation, while an important consideration, is not necessarily a part of the nursing
assessment.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-53, 54
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
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10. A patient states, ―I feel detached and weird all the time. It is as though I am looking at life
through a cloudy window. Everything seems unreal. It really messes up things at work and
school.‖ This scenario is most suggestive of which health problem? a. Acute stress disorder
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b. Dissociative amnesia
c. Depersonalization disorder
d. Disinhibited social engagement disorder
ANS: C
Depersonalization disorder involves a persistent or recurrent experience of feeling detached
from and outside oneself. Although reality testing is intact, the experience causes significant
impairment in social or occupational functioning and distress to the individual. Dissociative
amnesia involves memory loss. Children with disinhibited social engagement disorder
demonstrate no normal fear of strangers and are unusually willing to go off with strangers.
Individuals with ASD (Acute Stress Disorder) experience three or more dissociative
symptoms associated with a traumatic event, such as a subjective sense of numbing,
detachment, or absence of emotional responsiveness; a reduction in awareness of
surroundings; derealization; depersonalization or dissociative amnesia. In the scenario, the
patient experiences only one symptom.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Page 16-68 (Table 16-1) TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
11. The unlicensed assistive personnel (UAP) says to the nurse, ―That patient with amnesia looks
fine, but when I talk to her, she seems vague. What should I be doing for her?‖ Select the
nurse‘s best reply.
a. ―Spend as much time with her as you can and ask questions about her life.‖
b. ―Use short, simple sentences and keep the environment calm and protective.‖
c. ―Provide more information about her past to reduce the mysteries that are causing
anxiety.‖
d. ―Structure her time with activities to keep her busy, stimulated, and regaining
concentration.‖
ANS: B
Disruptions in ability to perform activities of daily living, confusion, and anxiety are often
apparent in patients with amnesia. Offering simple directions to promote activities of daily
living and reduce confusion helps increase feelings of safety and security. A calm, secure,
predictable, protective environment is also helpful when a person is dealing with a great deal
of uncertainty. Recollection of memories should proceed at its own pace, and the patient
should only gradually be given information about her past. Asking questions that require
recall that the patient does not possess will only add frustration. Quiet, undemanding activities
should be provided as the patient tolerates them and should be balanced with rest periods; the
patient‘s time should not be loaded with demanding or stimulating activities.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-68 (Table 16-2) TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
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12. A patient diagnosed with depersonalization disorder tells the nurse, ―It‘s starting again. I feel as
though I‘m going to float away.‖ Which intervention would be most appropriate at this point?
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a.
b.
c.
d.
Notify the health care provider of this change in the patient‘s behavior.
Engage the patient in a physical activity such as exercise.
Isolate the patient until the sensation has diminished.
Administer a prn dose of antianxiety medication.
ANS: B
Helping the patient apply a grounding technique, such as exercise, assists the patient to
interrupt the dissociative process. Medication can help reduce anxiety but does not directly
interrupt the dissociative process. Isolation would allow the sensation to overpower the
patient. It is not necessary to notify the health care provider.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-8, 10, 48, 69 (Table 16-2)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
13. A person runs from a crowded nightclub after a pyrotechnics show causes the building to catch
fire. Which division of the autonomic nervous system will be stimulated in response to this
experience?
a. Limbic system
b. Peripheral nervous system
c. Sympathetic nervous system
d. Parasympathetic nervous system
ANS: C
The autonomic nervous system is comprised of the sympathetic (fight or flight response) and
parasympathetic nervous system (relaxation response). In times of stress, the sympathetic
nervous system is stimulated. A person would experience stress associated with the
experience of being in danger. The peripheral nervous system responds to messages from the
sympathetic nervous system. The limbic system processes emotional responses but is not
specifically part of the autonomic nervous system.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 16-15, 16, 67 (Fig 16-1)
TOP: Nursing Process: Assessment MSC:
Client Needs: Physiological Integrity
14. The gas pedal on a person‘s car became stuck on a busy interstate highway, causing the car to
accelerate rapidly. For 20 minutes, the car was very difficult to control. In the months after this
experience, afterward, which assessment finding would the nurse expect? a. Weight gain
b. Flashbacks
c. Headache
d. Diuresis
ANS: B
The scenario depicts a frightening, traumatic, and stressful situation. Severe dissociation or
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
―mind flight‖ may occur for those who have suffered significant trauma. The episodic failure
of dissociation causes intrusive symptoms such as flashbacks. The problems identified in the
distracters may or may not occur.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 16-45 TOP:
Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
15. A soldier returns to the United States from active duty in a combat zone. The soldier is
diagnosed with PTSD. The nurse‘s highest priority is to screen this soldier for a. bipolar
disorder.
b. schizophrenia.
c. depression.
d. dementia.
ANS: C
Comorbidities for adults with PTSD include depression, anxiety disorders, sleep disorders,
and dissociative disorders. Incidence of the disorders identified in the distracters is similar to
the general population.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-16, 29
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
16. Two weeks ago, a soldier returned to the United States from active duty in a combat zone. The
soldier was diagnosed with PTSD. Which comment by the soldier requires the nurse‘s
immediate attention?
a. ―It‘s good to be home. I missed my home, family, and friends.‖
b. ―I saw my best friend get killed by a roadside bomb. I don‘t understand why it wasn‘t
me.‖
c. ―Sometimes I think I hear bombs exploding, but it‘s just the noise of traffic in my
hometown.‖
d. ―I want to continue my education, but I‘m not sure how I will fit in with other college
students.‖
ANS: B
The correct response indicates the soldier is thinking about death and feeling survivor‘s guilt.
These emotions may accompany suicidal ideation, which warrants the nurse‘s follow-up
assessment. Suicide is a high risk among military personnel diagnosed with PTSD. One
distracter indicates flashbacks, common with persons with PTSD, but not solely indicative
that further problems exist. The other distracters are normal emotions associated with
returning home and change.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 16-29, 32 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Analysis/Diagnosis
MSC: Client Needs: Psychosocial Integrity
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
17. A soldier returned home from active duty in a combat zone and was diagnosed with PTSD. The
soldier says, ―If there‘s a loud noise at night, I get under my bed because I think we‘re getting
bombed.‖ What type of experience has the soldier described? a. Illusion
b. Flashback
c. Nightmare
d. Auditory hallucination
ANS: B
Flashbacks are dissociative reactions in which an individual feels or acts as if the traumatic
event were recurring. Illusions are misinterpretations of stimuli, and although the experience
is similar, it is better termed a flashback because of the diagnosis of PTSD. Auditory
hallucinations have no external stimuli. Nightmares commonly accompany PTSD, but this
experience was stimulated by an actual environmental sound.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 16-6, 43, 44
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
18. A soldier returned 3 months ago from a combat zone and was diagnosed with PTSD. Which
social event would be most disturbing for this soldier? a. Halloween festival with neighborhood
children
b. Singing carols around a Christmas tree
c. A family outing to the seashore
d. Fireworks display on July 4th
ANS: D
The exploding noises associated with fireworks are likely to provoke exaggerated responses
for this soldier. The distracters are not associated with offensive sounds.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 16-6, 43, 44
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
19. Which comment by the parents of young children best demonstrates support of development of
resilience and effective stress management?
a. ―Our children will be stronger if they make their own decisions.‖
b. ―We spend daily family time talking about experiences and feelings.‖
c. ―We use three different babysitters. All of them have college degrees.‖
d. ―Our parenting strategies are different from those our own parents used.‖
ANS: B
The correct response demonstrates consistent nurturing, which is a vital component of
building resilience in children. The incorrect responses are not necessarily unhealthy
parenting behaviors, but they do not clearly demonstrate parental nurturing.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-14, 18
TOP: Nursing Process: Assessment
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
MSC: Client Needs: Psychosocial Integrity
20. A soldier in a combat zone tells the nurse, ―I saw a child get blown up over a year ago, and I
still keep seeing bits of flesh everywhere. I see something red, and the visions race back to my
mind.‖ Which phenomenon associated with PTSD is the soldier describing? a. Reexperiencing
b. Hyperarousal
c. Avoidance
d. Psychosis
ANS: A
Spontaneous or cued recurrent, involuntary, and intrusive distressing memories of the
traumatic events are often associated with PTSD. The soldier has described intrusive thoughts
and visions associated with reexperiencing the traumatic event. This description does not
indicate psychosis, hypervigilance, or avoidance.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 16-27
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
21. A soldier who served in a combat zone returned to the United States. The soldier‘s spouse
complains to the nurse, ―We had planned to start a family, but now he won‘t talk about it. He
won‘t even look at children.‖ The spouse is describing which symptom associated with PTSD?
a. Reexperiencing
b. Hyperarousal
c. Avoidance
d. Psychosis
ANS: C
Physiological reactions to reminders of the event that include persistent avoidance of stimuli
associated with the trauma results in the individual‘s avoiding talking about the event or
avoiding activities, people, or places that arouse memories of the trauma. Avoidance is
exemplified by a sense of foreshortened future and estrangement. There is no evidence this
soldier is having hyperarousal or reexperiencing war-related traumas. Psychosis is not
evident.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 16-29
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
22. A soldier returned home last year after deployment to a war zone. The soldier‘s spouse
complains, ―We were going to start a family, but now he won‘t talk about it. He will not look at
children. I wonder if we‘re going to make it as a couple.‖ Select the nurse‘s best response. a.
―Posttraumatic stress disorder (PTSD) often changes a person‘s sexual functioning.‖
b. ―I encourage you to continue to participate in social activities where children are present.‖
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
c. ―Have you talked with your spouse about these reactions? Sometimes we just need to
confront behavior.‖
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d. ―Posttraumatic stress disorder often strains relationships. Here are some
community resources for help and support.‖
ANS: D
PTSD precipitates changes that can lead to divorce. It is important to provide support to both
the veteran and spouse. Confrontation will not be effective. While it is important to provide
information, on-going support will be more effective.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-24, 31, 51
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
23. Which assessment finding best supports dissociative fugue? The patient states
a. ―I cannot recall why I‘m living in this town.‖
b. ―I feel as if I‘m living in a fuzzy dream state.‖
c. ―I feel like different parts of my body are at war.‖
d. ―I feel very anxious and worried about my problems.‖
ANS: A
The patient in a fugue state frequently relocates and assumes a new identity while not
recalling previous identity or places previously inhabited. The distracters are more consistent
with depersonalization disorder, generalized anxiety disorder, or dissociative identity disorder.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 16-49
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
24. After major reconstructive surgery, a patient‘s wounds dehisced. Extensive wound care was
required for 6 months, causing the patient to miss work and social activities. Which
physiological response would be expected for this patient? a. Vital signs return to normal.
b. Release of endogenous opioids would cease.
c. Pulse and blood pressure readings are elevated.
d. Psychomotor abilities of the right brain become limited.
ANS: A
The scenario presents chronic and potentially debilitating stress. The helpless and out of
control feelings produce pathophysiological changes. Unmyelinated ventral vagus responses
initially result in rapid heart rate and respiration. After many hours, days, or months the body
cannot sustain this state, so the dorsal vagal response dampens the sympathetic nervous
system. This parasympathetic response results in the heart rate and respiration slowing down
and a decrease in blood pressure. Individuals with dissociative disorders have altered
communication between higher and lower brain structures due to the massive release of
endogenous opioids at the time of severe threat.
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PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 16-15, 16
TOP: Nursing Process: Assessment
MSC: Client Needs: Physiological Integrity
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
25. Relaxation techniques help patients who have experienced major traumas because they
a. engage the parasympathetic nervous system.
b. increase sympathetic stimulation.
c. increase the metabolic rate.
d. release hormones.
ANS: A
In response to trauma, the sympathetic arousal symptoms of rapid heart rate and rapid
respiration prepare the person for flight or fight responses. Afterward, the dorsal vagal
response damps down the sympathetic nervous system. This is a parasympathetic response
with the heart rate and respiration slowing down and decreasing the blood pressure.
Relaxation techniques promote activity of the parasympathetic nervous system.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 16-30, 31, 36
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
26. Select the correct etiology to complete this nursing diagnosis for a patient diagnosed with
dissociative identity disorder. Disturbed personal identity related to a. obsessive fears of
harming self or others.
b. poor impulse control and lack of self-confidence.
c. depressed mood secondary to nightmares and intrusive thoughts.
d. cognitive distortions associated with unresolved childhood abuse issues.
ANS: D
Nearly all patients with dissociative identity disorder have a history of childhood abuse or
trauma. None of the other etiology statements is relevant.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-50, 68 (Table 16-1)
TOP: Nursing Process: Analysis/Diagnosis
MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A young adult says, ―I was sexually abused by my older brother. During those assaults, I went
somewhere else in my mind. I don‘t remember the details. Now, I often feel numb or unreal in
romantic relationships, so I just avoid them.‖ Which disorders should the nurse suspect based on
this history? (Select all that apply.) a. Acute stress disorder
b. Depersonalization disorder
c. Generalized anxiety disorder
d. PTSD
e. Reactive attachment disorder
f. Disinhibited social engagement disorder
ANS: A, B, D
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Acute stress disorder, depersonalization disorder, and PTSD can involve dissociative
elements, such as numbing, feeling unreal, and being amnesic for traumatic events. All three
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disorders are also responses to acute stress or trauma, which has occurred here. The distracters
are disorders not evident in this patient‘s presentation. Generalized anxiety disorder involves
extensive worrying that is disproportionate to the stressors or foci of the worrying. Reactive
attachment disorder and disinhibited social engagement disorder are problems of childhood.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 16-3, 5
(DSM-5 Box), 29, 37 (DSM-5 Box), 48, 49
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
2. A 10-year-old child was placed in a foster home after being removed from parental contact
because of abuse. The child has apprehension, tremulousness, and impaired concentration. The
foster parent also reports the child has an upset stomach, urinates frequently, and does not
understand what has happened. What helpful measures should the nurse suggest to the foster
parents? The nurse should recommend (Select all that apply)
a. conveying empathy and acknowledging the child‘s distress.
b. explaining and reinforcing reality to avoid distortions.
c. using a calm manner and low, comforting voice.
d. avoiding repetition in what is said to the child.
e. staying with the child until the anxiety decreases.
f. minimizing opportunities for exercise and play.
ANS: A, B, C, E
The child‘s symptoms and behavior suggest that he is exhibiting PTSD. Interventions
appropriate for this level of anxiety include using a calm, reassuring tone, acknowledging the
child‘s distress, repeating content as needed when there is impaired cognitive processing and
memory, providing opportunities for comforting and normalizing play and physical activities,
correcting any distortion of reality, and staying with the child to increase his sense of security.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 16-24 to 26, 71 (Box 16-1) TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
3. The nurse interviewing a patient with suspected PTSD should be alert to findings indicating the
patient (Select all that apply)
a. avoids people and places that arouse painful memories.
b. experiences flashbacks or re-experiences the trauma.
c. experiences symptoms suggestive of a heart attack.
d. feels compelled to repeat selected ritualistic behaviors.
e. demonstrates hypervigilance or distrusts others.
f. feels detached, estranged, or empty inside.
ANS: A, B, C, E, F
These assessment findings are consistent with the symptoms of PTSD. Ritualistic behaviors
are expected in obsessive-compulsive disorder.
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PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 16-5 (DSM-5 Box), 27, 28, 32 (Case Study and Nursing Care Plan)
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TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
4. Which experiences are most likely to precipitate PTSD? (Select all that apply).
a. A young adult bungee jumped from a bridge with a best friend.
b. An 8-year-old child watched an R-rated movie with both parents.
c. An adolescent was kidnapped and held for 2 years in the home of a sexual predator.
d. A passenger was in a bus that overturned on a sharp curve and tumbled down an
embankment.
e. An adult was trapped for 3 hours at an angle in an elevator after a portion of the
supporting cable breaks.
ANS: C, D, E
PTSD usually occurs after a traumatic event that is outside the range of usual experience.
Examples are childhood physical abuse, torture/kidnap, military combat, sexual assault, and
natural disasters, such as floods, tornados, earthquakes, tsunamis; human disasters, such as a
bus or elevator accident; or crime-related events, such being taken hostage. The common
element in these experiences is the individual‘s extraordinary helplessness or powerlessness in
the face of such stressors. Bungee jumps by adolescents are part of the developmental task
and might be frightening, but in an exhilarating way rather than a harmful way. A child may
be disturbed by an R-rated movie, but the presence of the parents would modify the
experience in a positive way.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 16-2, 4, 5, 27
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
Chapter 17: Somatic Symptom Disorders
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1. Which assessment data would help the health care team distinguish symptoms of
conversion (functional neurological) disorder from symptoms of illness anxiety disorder
(hypochondriasis)?
a. Voluntary control of symptoms
b. Patient‘s style of presentation
c. Results of diagnostic testing
d. The role of secondary gains
ANS: B
Patients with illness anxiety disorder (hypochondriasis) tend to be more anxious about their
concerns and display more obsessive attention to detail, whereas the patients with conversion
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(functional neurological) disorder often exhibit less concern with the symptom they are
presenting than would be expected. Neither disorder involves voluntary control of the
symptoms. Results of diagnostic testing for both would be negative (i.e., no physiological
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basis would be found for the symptoms). Secondary gains can occur in both disorders but are
not necessary to either. See relationship to audience response question.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-6 to 9
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
2. Which prescription medication would the nurse expect to be prescribed for a patient
diagnosed with a somatic symptom disorder?
a. Narcotic analgesics for use as needed for acute pain
b. Antidepressant medications to treat co-morbid depression
c. Long-term use of benzodiazepines to support coping with anxiety
d. Conventional antipsychotic medications to correct cognitive distortions
ANS: B
Various types of antidepressants may be helpful in somatic disorders not only directly by
reducing depressive symptoms and hence somatic responses, but also indirectly by affecting
nerve circuits that affect not only mood but also fatigue, pain perception, GI distress, and
other somatic symptoms. Patients may benefit from short-term use of antianxiety medication
(benzodiazepines) but require careful monitoring because of risks of dependence.
Conventional antipsychotic medications would not be used, although selected atypical
antipsychotics may be useful. Narcotic analgesics are not indicated.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-18, 24
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
3. A medical-surgical nurse works with a patient diagnosed with a somatic symptom disorder.
Care planning is facilitated by understanding that the patient will probably a. readily seek
psychiatric counseling.
b. be resistant to accepting psychiatric help.
c. attend psychotherapy sessions without encouragement.
d. be eager to discover the true reasons for physical symptoms.
ANS: B
Patients with somatic symptom disorders go from one health care provider to another trying to
establish a physical cause for their symptoms. When a psychological basis is suggested and a
referral for counseling offered, these patients reject both.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-29, 30
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
4. A patient has blindness related to conversion (functional neurological) disorder but is
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unconcerned about this problem. Which understanding should guide the nurse‘s planning for
this patient?
a. The patient is suppressing accurate feelings regarding the problem.
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b. The patient‘s anxiety is relieved through the physical symptom.
c. The patient‘s optic nerve transmission has been impaired.
d. The patient will not disclose genuine fears.
ANS: B
Psychoanalytical theory suggests conversion reduces anxiety through production of a physical
symptom symbolically linked to an underlying conflict. Conversion, not suppression, is the
operative defense mechanism in this disorder. While some MRI studies suggest that patients
with conversion disorder have an abnormal pattern of cerebral activation, there is no actual
alternation of nerve transmission. The other distracters oversimplify the dynamics, suggesting
that only dependency needs are of concern, or suggest conscious motivation (conversion
operates unconsciously).
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-8, 9
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
5. A patient has blindness related to conversion (functional neurological) disorder. To help the
patient eat, the nurse should
a. establish a ―buddy‖ system with other patients who can feed the patient at each meal.
b. expect the patient to feed self after explaining arrangement of the food on the tray.
c. direct the patient to locate items on the tray independently and feed self.
d. address needs of other patients in the dining room, then feed this patient.
ANS: B
The patient is expected to maintain some level of independence by feeding self, while the
nurse is supportive in a matter-of-fact way. The distracters support dependency or offer little
support.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-27, 28
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
6. A patient with blindness related to conversion (functional neurological) disorder says, ―All the
doctors and nurses in the hospital stop by often to check on me. Too bad people outside the
hospital don‘t find me as interesting.‖ Which nursing diagnosis is most relevant? a. Social
isolation
b. Chronic low self-esteem
c. Interrupted family processes
d. Ineffective health maintenance
ANS: B
The patient mentions that the symptoms make people more interested. This indicates that the
patient feels uninteresting and unpopular without the symptoms, thus supporting the nursing
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diagnosis of chronic low self-esteem. Defining characteristics for the other nursing diagnoses
are not present in the scenario.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-23, 28, 58 (Table 17-3) TOP: Nursing Process: Diagnosis/Analysis MSC:
Client Needs: Psychosocial Integrity
7. To assist patients diagnosed with somatic symptom disorders, nursing interventions of high
priority
a. explain the pathophysiology of symptoms.
b. help these patients suppress feelings of anger.
c. shift focus from somatic symptoms to feelings.
d. investigate each physical symptom as it is reported.
ANS: C
Shifting the focus from somatic symptoms to feelings or to neutral topics conveys interest in
the patient as a person rather than as a condition. The need to gain attention with the use of
symptoms is reduced over the long term. A desired outcome would be that the patient would
express feelings, including anger if it is present. Once physical symptoms are investigated,
they do not need to be reinvestigated each time the patient reports them.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-28, 60 (Table 17-4)
TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
8. A patient with fears of serious heart disease was referred to the mental health center by a
cardiologist. Extensive diagnostic evaluation showed no physical illness. The patient says, ―My
chest is tight, and my heart misses beats. I‘m often absent from work. I don‘t go out much
because I need to rest.‖ Which health problem is most likely? a. Dysthymic disorder
b. Somatic symptom disorder
c. Antisocial personality disorder
d. Illness anxiety disorder (hypochondriasis)
ANS: D
Illness anxiety disorder (hypochondriasis) involves preoccupation with fears of having a
serious disease even when evidence to the contrary is available. The preoccupation causes
impairment in social or occupational functioning. Somatic symptom disorder involves fewer
symptoms. Dysthymic disorder is a disorder of lowered mood. Antisocial disorder applies to a
personality disorder in which the individual has little regard for the rights of others. See
relationship to audience response question.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-6, 7
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
9. A nurse assessing a patient diagnosed with a somatic symptom disorder is most likely to note that
the patient
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a. sees a relationship between symptoms and interpersonal conflicts.
b. has little difficulty communicating emotional needs to others.
c. rarely derives personal benefit from the symptoms.
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d. has altered comfort and activity needs.
ANS: D
The patient frequently has altered comfort and activity needs associated with the symptoms
displayed (fatigue, insomnia, weakness, tension, pain, etc.). In addition, hygiene, safety, and
security needs may also be compromised. The patient is rarely able to see a relation between
symptoms and events in his or her life, which is readily discernible to health professionals.
Patients with somatic symptom disorders often derive secondary gain from their symptoms
and/or have considerable difficulty identifying feelings and conveying emotional needs to
others.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-18, 19, 36 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
10. To plan effective care for patients diagnosed with somatic symptom disorders, the nurse should
understand that patients have difficulty giving up the symptoms because the symptoms a. are
generally chronic.
b. have a physiological basis.
c. can be voluntarily controlled.
d. provide relief from health anxiety.
ANS: D
At the unconscious level, the patient's primary gain from the symptoms is anxiety relief.
Considering that the symptoms actually make the patient more psychologically comfortable
and may also provide secondary gain, patients frequently fiercely cling to the symptoms. The
symptoms tend to be chronic, but that does not explain why they are difficult to give up. The
symptoms are not under voluntary control or physiologically based.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-18, 19, 36 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
11. A patient with a somatic symptom disorder has the nursing diagnosis Interrupted family
processes related to patient‟s disabling symptoms as evidenced by spouse and children
assuming roles and tasks that previously belonged to patient. An appropriate outcome is that the
patient will
a. assume roles and functions of other family members.
b. demonstrate performance of former roles and tasks.
c. focus energy on problems occurring in the family.
d. rely on family members to meet personal needs.
ANS: B
The patient with a somatic symptom disorder has typically adopted a sick role in the family,
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characterized by dependence. Increasing independence and resumption of former roles are
necessary to change this pattern. The distracters are inappropriate outcomes.
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PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-23, 24, 36 (Case Study and Nursing Care Plan)
TOP:
Nursing Process: Outcomes Identification
MSC: Client Needs: Psychosocial Integrity
12. Which comment by a patient who recently experienced a myocardial infarction indicates use of
maladaptive, ineffective coping strategies?
a. ―My employer should have paid for a health club membership for me.‖
b. ―My family will see me through this. It won‘t be easy, but I will never be alone.‖
c. ―My heart attack was no fun, but it showed me up the importance of a good diet and more
exercise.‖
d. ―I accept that I have heart disease. Now I need to decide if I will be able to
continue
my work daily.‖
ANS: A
Blaming someone else and rationalizing one‘s failure to exercise are not adaptive coping
strategies. Seeing the glass as half full, using social and religious supports, and confronting
one‘s situation are seen as more effective strategies. The distracters demonstrate effective
coping associated with a serious medical condition.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-9 to 12
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
13. A nurse assesses a patient diagnosed with conversion (functional neurological) disorder. Which
comment is most likely from this patient?
a. ―Since my father died, I‘ve been short of breath and had sharp pains that go down my left
arm, but I think it‘s just indigestion.‖
b. ―I have daily problems with nausea, vomiting, and diarrhea. My skin is very dry, and I
think I‘m getting seriously dehydrated.‖
c. ―Sexual intercourse is painful. I pretend as if I‘m asleep so I can avoid it. I think it‘s
starting to cause problems with my marriage.‖
d. ―I get choked very easily and have trouble swallowing when I eat. I think I might
have cancer of the esophagus.‖
ANS: A
Patients with conversion (functional neurological) disorder demonstrate a lack of concern
regarding the seriousness of symptoms. This lack of concern is termed la belle indifférence.
There is also a specific, identifiable cause for the development of the symptoms; in this
instance, the death of a parent would precipitate stress. The distracters relate to sexual
dysfunction and illness anxiety disorder.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-8, 9
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
14. A patient who experienced a myocardial infarction was transferred from critical care to a step-
down unit. The patient then used the call bell every 15 minutes for minor requests and
complaints. Staff nurses reported feeling inadequate and unable to satisfy the patient‘s needs.
When the nurse manager intervenes directly with this patient, which comment is most
therapeutic?
a. ―I‘m wondering if you are feeling anxious about your illness and being left alone.‖
b. ―The staff are concerned that you are not satisfied with the care you are receiving.‖
c. ―Let‘s talk about why you use your call light so frequently. It is a problem.‖
d. ―You frustrate the staff by calling them so often. Why are you doing that?‖
ANS: A
This patient is experiencing anxiety associated with a serious medical condition. Verbalization
is an effective outlet for anxiety. ―I‘m wondering if you are anxious …‖ focuses on the
emotions underlying the behavior rather than the behavior itself. This opening conveys the
nurse‘s willingness to listen to the patient‘s feelings and an understanding of the commonly
seen concern about not having a nurse always nearby as in the intensive care unit. The other
options focus on the behavior or its impact on nursing and do not help the patient with her
emotional needs.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-9 to 12
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
15. A patient reports fears of having cervical cancer and says to the nurse, ―I‘ve had Pap smears by
six different doctors. The results were normal, but I‘m sure that‘s because of errors in the
laboratory.‖ Which disorder would the nurse suspect? a. Conversion (functional neurological)
disorder
b. Illness anxiety disorder (hypochondriasis)
c. Somatic symptom disorder
d. Factitious disorder
ANS: B
Patients with illness anxiety disorder have fears of serious medical problems, such as cancer
or heart disease. These fears persist despite medical evaluations and interfere with daily
functioning. There are no complaints of pain. There is no evidence of factitious or conversion
disorder.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-6, 7
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
16. A patient diagnosed with a somatic symptom disorder says, ―My pain is from an undiagnosed
injury. I can‘t take care of myself. I need pain medicine six or seven times a day. I feel like a
baby because my family has to help me so much.‖ It is important for the nurse to assess a.
mood.
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
b. cognitive style.
c. secondary gains.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
d. identity and memory.
ANS: C
Secondary gains should be assessed. The patient‘s dependency needs may be met through care
from the family. When secondary gains are prominent, the patient is more resistant to giving
up the symptom. The scenario does not allude to a problem of mood. Cognitive style and
identity and memory assessment are of lesser concern because the patient‘s diagnosis has
been established.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-21, 58 (Table 17-3) | Pages 17-28, 60 (Table 17-4)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
17. What is an essential difference between somatic symptom disorders and factitious disorders?
a. Somatic symptom disorders are under voluntary control, whereas factitious disorders
are unconscious and automatic.
b. Factitious disorders are precipitated by psychological factors, whereas somatic
symptom disorders are related to stress.
c. Factitious disorders are individually determined and related to childhood sexual
abuse, whereas somatic symptom disorders are culture bound.
d. Factitious disorders are under voluntary control, whereas somatic symptom
disorders involve expression of psychological stress through somatization.
ANS: D
The key is the only fully accurate statement. Somatic symptom disorders involve expression
of stress through bodily symptoms and are not under voluntary control or culture bound.
Factitious disorders are under voluntary control. See relationship to audience response
question.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-19, 31, 32
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
18. A patient says, ―I know I have a brain tumor despite the results of the MRI. The radiologist is
wrong. People who have brain tumors vomit, and yesterday I vomited all day.‖ Which response
by the nurse fosters cognitive reframing?
a. ―You do not have a brain tumor. The more you talk about it, the more it reinforces your
belief.‖
b. ―Let‘s see if there are any other possible explanations for your vomiting.‖
c. ―You seem so worried. Let‘s talk about how you‘re feeling.‖
d. ―We need to talk about something else.‖
ANS: B
Questioning the evidence is a cognitive reframing technique. Identifying causes other than the
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
feared disease can be helpful in changing distorted perceptions. Distraction by changing the
subject will not be effective.
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-25, 30
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
19. Which treatment modality should a nurse recommend to help a patient diagnosed with a
somatic symptom disorder to cope more effectively? a. Flooding
b. Response prevention
c. Relaxation techniques
d. Systematic desensitization
ANS: C
Somatic symptom disorders are commonly associated with complicated reactions to stress.
These reactions are accompanied by muscle tension and pain. Relaxation can diminish the
patient‘s perceptions of pain and reduce muscle tension. The distracters are modalities useful
in treating selected anxiety disorders.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-25 to 27, 60 (Table 17-4) TOP: Nursing Process: Planning MSC:
Client Needs: Physiological Integrity
20. Which assessment question could a nurse ask to help identify secondary gains associated with
a somatic symptom disorder?
a. ―What are you unable to do now but were previously able to do?‖
b. ―How many doctors have you seen in the last year?‖
c. ―Who do you talk to when you‘re upset?‖
d. ―Did you experience abuse as a child?‖
ANS: A
Secondary gains should be assessed. Secondary gains reinforce maladaptive behavior. The
patient‘s dependency needs may be evident through losses of abilities. When secondary gains
are prominent, the patient is more resistant to giving up the symptom. There may be a history
of abuse or doctor shopping, but the question does not assess the associated gains.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 17-21 TOP:
Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
21. A patient diagnosed with a somatic symptom disorder has been in treatment for 4 weeks. The
patient says, ―Although I‘m still having pain, I notice it less and am able to perform more
activities.‖ The nurse should evaluate the treatment plan as a. marginally successful.
b. minimally successful.
c. partially successful.
d. totally achieved.
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Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
ANS: C
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
Decreased preoccupation with symptoms and increased ability to perform activities of daily
living suggest partial success of the treatment plan. Total success is rare because of patient
resistance.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-23, 24, 31
TOP: Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A child has a history of multiple hospitalizations for recurrent systemic infections. The
child is not improving in the hospital, despite aggressive treatment. Factitious disorder
imposed on another is suspected. Which nursing interventions are appropriate? (Select all
that apply.) a. Increase private visiting time for the parents to improve bonding.
b. Keep careful, detailed records of visitation and untoward events.
c. Place mittens on the child to reduce access to ports and incisions.
d. Encourage family members to visit in groups of two or three.
e. Interact with the patient frequently during visiting hours.
ANS: B, D, E
Factitious disorder imposed on another is a condition wherein a person intentionally causes or
perpetuates the illness of a loved one (e.g., by periodically contaminating IV solutions with
fecal material). When this disorder is suspected, the child‘s life could be at risk. Depending on
the evidence supporting this suspicion, interventions could range from minimizing
unsupervised visitation to blocking visitation altogether. Frequently checking on the child
during visitation and minimizing unobserved access to the child (by encouraging small group
visits) reduces the opportunity to take harmful action and increases the collection of data that
can help determine whether this disorder is at the root of the child‘s illness. Detailed tracking
of visitation and untoward events helps identify any patterns there might be between select
visitors and the course of the child‘s illness. Increasing private visitation provides more
opportunity for harm. Educating visitors about aseptic techniques would not be of help if the
infections are intentional, and preventing inadvertent contamination by the child himself
would not affect factitious disorder by proxy.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-34, 35
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
2. Which assessment findings suggest the possibility of a factitious disorder, imposed on self-type?
(Select all that apply.)
a. History of multiple hospitalizations without findings of physical illness
b. History of multiple medical procedures or exploratory surgeries
c. Going from one doctor to another seeking the desired response
d. Claims illness to obtain financial benefit or other incentive
e. Difficulty describing symptoms
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ANS: A, B
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
Health Nursing A Clinical 9th Edition by Margaret Jordan
Halter |Test Bank|Chapter 1-36 UPDATED 2022
Persons with factitious disorders, imposed on self-type, typically have a history of multiple
hospitalizations and medical workups, with negative findings from workups. Sometimes they
have even had multiple surgeries seeking the origin of the physical complaints. If they do not
receive the desired response from a hospitalization, they may elope or accuse staff of
incompetence. Such persons usually seek treatment through a consistent health care provider
rather than doctor shopping, are not motivated by financial gain or other external incentives,
and present symptoms in a very detailed, plausible manner indicating considerable
understanding of the disorder or presentation they are mimicking. See relationship to audience
response question.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 1732 TOP: Nursing Process: Implementation
MSC: Client Needs:
Psychosocial Integrity
3. A patient diagnosed with a somatic symptom disorder says, ―Why has God chosen me to be sick
all the time and unable to provide for my family? The burden on my family is worse than the
pain I bear.‖ Which nursing diagnoses apply to this patient? (Select all that apply.) a. Spiritual
distress
b. Decisional conflict
c. Adult failure to thrive
d. Impaired social interaction
e. Ineffective role performance
ANS: A, E
The patient‘s verbalization is consistent with spiritual distress. The patient‘s description of
being unable to provide for and burdening the family indicates ineffective role performance.
No data support diagnoses of adult failure to thrive, impaired social interaction, or decisional
conflict.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-23, 24, 58 (Table 17-3) TOP: Nursing Process: Diagnosis/Analysis MSC:
Client Needs: Psychosocial Integrity
4. A nurse assesses a patient suspected of having somatic symptom disorder. Which assessment
findings regarding this patient support the suspected diagnosis? (Select all that apply.) a. Female
b. Reports frequent syncope
c. Rates pain as ―1‖ on a scale of ―10‖
d. First diagnosed with psoriasis at age 12
e. Reports insomnia often results from back pain
ANS: A, B, E
There is no chronic disease to explain the symptoms for patients with somatic symptom
disorder. Patients report multiple symptoms; gastrointestinal and pseudoneurological
symptoms are common. This disorder is more common in women than in men. Patients with
conversion disorder would have a tendency to underrate pain.
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 17-2 to 4
TOP: Nursing Process: Assessment
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
MSC: Client Needs: Psychosocial Integrity
5. A nurse‘s neighbor says, ―I saw a news story about a man without any known illness who died
suddenly after his ex-wife committed suicide. Was that a coincidence, or can emotional shock be
fatal?‖ The nurse should respond by noting that some serious medical conditions may be
complicated by emotional stress, including (Select all that apply) a. cancer.
b. hip fractures.
c. hypertension.
d. immune disorders.
e. cardiovascular disease.
ANS: A, C, D, E
A number of diseases can be worsened or brought to awareness by intense emotional stress.
Immune disorders can be complicated associated with detrimental effects of stress on the
immune system. Others can be brought about indirectly, such as cardiovascular disease due to
acute or chronic hypertension. Hip fractures are not in this group.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 17-9 to 12, 51 (Table 17-1) TOP: Nursing Process: Implementation MSC:
Client Needs: Psychosocial Integrity
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Disorientation to place and time is an expected finding. Orientation to person (self) usually
remains intact. Attention span is short, and difficulty focusing or shifting attention as directed
is often noted. Patients with delirium commonly experience illusions and hallucinations.
Fluctuating levels of consciousness are expected. Agnosia occurs with dementia. Apathy is
associated with depression.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 23-3, 4, 45 (Table 23-4)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
3. Which nursing diagnoses are most applicable for a patient diagnosed with severe late stage
Alzheimer‘s disease? (Select all that apply.) a. Acute confusion
b. Anticipatory grieving
c. Urinary incontinence
d. Disturbed sleep pattern
e. Risk for caregiver role strain
ANS: C, D, E
The correct answers are consistent with problems frequently identified for patients with latestage Alzheimer‘s disease. Confusion is chronic, not acute. The patient‘s cognition is too
impaired to grieve.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 23-21, 49 (Table 23-6) | Page 23-30 (Case Study and Nursing Care Plan 23-1)
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
Chapter 24: Personality Disorders
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1.
A health care provider recently convicted of Medicare fraud says to a nurse, ―Sure I overbilled.
Everyone takes advantage of the government. There are too many rules to follow and I deserve
the money.‖ These statements show a. shame.
b. suspiciousness.
c. superficial remorse.
d. lack of guilt feelings.
ANS: D
Rationalization is being used to explain behavior and deny wrongdoing. The individual who
does not believe he or she has done anything wrong will not manifest anxiety, remorse, or
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guilt about the act. The patient‘s remarks cannot be assessed as shameful. Lack of trust and
concern that others are determined to do harm is not shown.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Pages 24-24,
25, 58 (Table 24-1), 60 (Table 24-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
2.
Which intervention is appropriate for an individual diagnosed with an antisocial personality
disorder who frequently manipulates others?
a. Refer requests and questions related to care to the case manager.
b. Encourage the patient to discuss feelings of fear and inferiority.
c. Provide negative reinforcement for acting-out behavior.
d. Ignore, rather than confront, inappropriate behavior.
ANS: A
Manipulative people frequently make requests of many different staff, hoping one will give in.
Having one decision maker provides consistency and avoids the potential for playing one staff
member against another. Positive reinforcement of appropriate behaviors is more effective
than negative reinforcement. The behavior should not be ignored; judicious use of
confrontation is necessary. Patients with antisocial personality disorders rarely have feelings
of fear and inferiority.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 24-24 | Pages 24-60 (Table 24-2), 24-66 (Box 24-2)
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
3.
As a nurse prepares to administer medication to a patient diagnosed with a borderline
personality disorder, the patient says, ―Just leave it on the table. I‘ll take it when I finish
combing my hair.‖ What is the nurse‘s best response?
a. Reinforce this assertive action by the patient. Leave the medication on the table as
requested.
b. Respond to the patient, ―I‘m worried that you might not take it. I‘ll come back later.‖
c. Say to the patient, ―I must watch you take the medication. Please take it now.‖
d. Ask the patient, ―Why don‘t you want to take your medication now?‖
ANS: C
The individual with a borderline personality disorder characteristically demonstrates
manipulative, splitting, and self-destructive behaviors. Consistent limit setting is vital not only
for the patient‘s safety, but also to prevent splitting other staff. ―Why‖ questions are not
therapeutic.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-42, 60 (Table 24-2), 66 (Box 24-2)
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
4.
What is an appropriate initial outcome for a patient diagnosed with a personality disorder who
frequently manipulates others? The patient will a. identify when feeling angry.
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b. use manipulation only to get legitimate needs met.
c. acknowledge manipulative behavior when it is called to his or her attention.
d. accept fulfillment of his or her requests within an hour rather than immediately.
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ANS: C
This is an early outcome that paves the way for later taking greater responsibility for
controlling manipulative behavior. Identifying anger relates to anger and aggression control.
Using manipulation to get legitimate needs is an inappropriate outcome. The patient would
ideally use assertive behavior to promote need fulfillment. Accepting fulfillment of requests
within an hour rather than immediately relates to impulsivity control.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-24, 42 | Pages 24-60 (Table 24-2), 66 (Box 24-2)
Nursing Process: Outcomes Identification
MSC: Client Needs: Psychosocial Integrity
5.
TOP:
Consider this comment to three different nurses by a patient diagnosed with an antisocial
personality disorder, ―Another nurse said you don‘t do your job right.‖ Collectively, these
interactions can be assessed as a. seductive.
b. detached.
c. manipulative.
d. guilt-producing.
ANS: C
Patients manipulate and control staff in various ways. By keeping staff off balance or fighting
among themselves, the person with an antisocial personality disorder is left to operate as he or
she pleases. Seductive behavior has sexual connotations. The patient is displaying the
opposite of detached behavior. Guilt is not evident in the comments.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-24, 60 (Table 24-2)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
6.
A nurse reports to the treatment team that a patient diagnosed with an antisocial personality
disorder has displayed the behaviors below. This patient is detached and superficial during
counseling sessions. Which behavior by the patient most clearly warrants limit setting? a.
Flattering the nurse
b. Lying to other patients
c. Verbal abuse of another patient
d. Detached superficiality during counseling
ANS: C
Limits must be set in areas in which the patient‘s behavior affects the rights of others.
Limiting verbal abuse of another patient is a priority intervention and particularly relevant
when interacting with a patient diagnosed with an antisocial personality disorder. The other
concerns should be addressed during therapeutic encounters.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Page 24-60 (Box 24-2) | Page 24-60 (Table 24-2) TOP: Nursing Process: Planning MSC:
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Client Needs: Safe, Effective Care Environment
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7.
A patient diagnosed with borderline personality disorder has a history of self-mutilation and
suicide attempts. The patient reveals feelings of depression and anger with life. Which type of
medication would the nurse expect to be prescribed? a. Benzodiazepine
b. Mood stabilizing medication
c. Monoamine oxidase inhibitor (MAOI)
d. Cholinesterase inhibitor
ANS: B
Mood stabilizing medications have been effective for many patients with borderline
personality disorder. Cholinesterase inhibitors are prescribed for persons diagnosed with
neurocognitive disorders. Use of anxiolytic medications is not supported by data given in the
scenario. MAOIs require great diligence in adherence to a restricted diet and are rarely used
for patients who are impulsive.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 24-48 TOP:
Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
8.
A person‘s spouse filed charges after repeatedly being battered. The person sarcastically says,
―I‘m sorry for what I did. I need psychiatric help.‖ Which statement by this person supports an
antisocial personality disorder?
a. ―I have a quick temper, but I can usually keep it under control.‖
b. ―I‘ve done some stupid things in my life, but I‘ve learned a lesson.‖
c. ―I‘m feeling terrible about the way my behavior has hurt my family.‖
d. ―I hit because I am tired of being nagged. My spouse deserves the beating.‖
ANS: D
The person with an antisocial personality disorder often impulsively acts out feelings of anger
and feels no guilt or remorse. Persons with antisocial personality disorders rarely seem to
learn from experience or feel true remorse. Problems with anger management and impulse
control are common.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-24, 25, 60 (Table 24-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
9.
What is the priority nursing diagnosis for a patient diagnosed with antisocial personality
disorder who has made threats against staff, ripped art off the walls, and thrown objects? a.
Risk for other-directed violence
b. Risk for self-directed violence
c. Impaired social interaction
d. Ineffective denial
ANS: A
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Violence against property, along with threats to harm staff, makes this diagnosis the priority.
Patients with antisocial personality disorders have impaired social interactions, but the risk for
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harming others is a higher priority. They direct violence toward others; not self. When patients
with antisocial personality disorders use denial, they use it effectively.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-28, 58 (Table 24-1)
TOP: Nursing Process: Diagnosis/Analysis MSC:
Client Needs: Safe, Effective Care Environment
10. When a patient diagnosed with a personality disorder uses manipulation to get needs met, the
staff applies limit-setting interventions. What is the correct rationale for this action? a. It
provides an outlet for feelings of anger and frustration.
b. It respects the patient‘s wishes, so assertiveness will develop.
c. External controls are necessary due to failure of internal control.
d. Anxiety is reduced when staff assumes responsibility for the patient‘s behavior.
ANS: C
A lack of internal controls leads to manipulative behaviors such as lying, cheating, conning,
and flattering. To protect the rights of others, external controls must be consistently
maintained until the patient is able to behave appropriately.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-24, 29, 42, 44, 60 (Table 24-2), 66 (Box 24-2)
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
11. One month ago, a patient diagnosed with borderline personality disorder and a history of self-
mutilation began dialectical behavior therapy. Today the patient phones to say, ―I feel empty
and want to hurt myself.‖ The nurse should
a. arrange for emergency inpatient hospitalization.
b. send the patient to the crisis intervention unit for 8 to 12 hours.
c. assist the patient to choose coping strategies for triggering situations.
d. advise the patient to take an antianxiety medication to decrease the anxiety level.
ANS: C
The patient has responded appropriately to the urge for self-harm by calling a helping
individual. A component of dialectical behavior therapy is telephone access to the therapist for
―coaching‖ during crises. The nurse can assist the patient to choose an alternative to selfmutilation. The need for a protective environment may not be necessary if the patient is able
to use cognitive strategies to determine a coping strategy that will reduce the urge to mutilate.
Taking a sedative and going to sleep should not be the first-line intervention because sedation
may reduce the patient‘s ability to weigh alternatives to mutilating behavior.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-49, 57 (Figure 24-1)
TOP: Nursing Process: Implementation MSC:
Client Needs: Safe, Effective Care Environment
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12. What is the most challenging nursing intervention with patients diagnosed with personality
disorders who use manipulation?
a. Supporting behavioral change
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b. Maintaining consistent limits
c. Monitoring suicide attempts
d. Using aversive therapy
ANS: B
Maintaining consistent limits is by far the most difficult intervention because of the patient‘s
superior skills at manipulation. Supporting behavioral change and monitoring patient safety
are less difficult tasks. Aversive therapy would probably not be part of the care plan because
positive reinforcement strategies for acceptable behavior seem to be more effective than
aversive techniques.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-29, 30, 44, 66 (Box 24-2) TOP: Nursing Process: Planning MSC:
Client Needs: Psychosocial Integrity
13. The history shows that a newly admitted patient is impulsive. The nurse would expect behavior
characterized by
a. adherence to a strict moral code.
b. manipulative, controlling strategies.
c. acting without thought on urges or desires.
d. postponing gratification to an appropriate time.
ANS: C
The impulsive individual acts in haste without taking time to consider the consequences of the
action. None of the other options describes impulsivity.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-32, 68 (Box 24-4)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
14. A patient says, ―I get in trouble sometimes because I make quick decisions and act on them.‖
Select the nurse‘s most therapeutic response.
a. ―Let‘s consider the advantages of being able to stop and think before acting.‖
b. ―It sounds as though you‘ve developed some insight into your situation.‖
c. ―I bet you have some interesting stories to share about overreacting.‖
d. ―It‘s good that you‘re showing readiness for behavioral change.‖
ANS: A
The patient is showing openness to learning techniques for impulse control. One technique is
to teach the patient to stop and think before acting impulsively. The patient can then be taught
to evaluate outcomes of possible actions and choose an effective action. The incorrect
responses shift the encounter to a social level or are judgmental.
PTS: 1
DIF: Cognitive Level: Apply (Application)
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REF: Pages 24-32, 68 (Box 24-4)
Client Needs: Psychosocial Integrity
TOP: Nursing Process: Implementation MSC:
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15. A patient diagnosed with borderline personality disorder was hospitalized several times after
multiple episodes of head banging and carving on both wrists. The patient remains impulsive.
Which nursing diagnosis is the initial focus of this patient‘s care? a. Self-mutilation
b. Impaired skin integrity
c. Risk for injury
d. Powerlessness
ANS: A
The scenario describes self-mutilation. Self-mutilation is a nursing diagnosis relating to
patient safety needs and is therefore of high priority. Impaired skin integrity and
powerlessness may be appropriate foci for care but are not the priority related to this therapy.
Risk for injury implies accidental injury, which is not the case for the patient with borderline
personality disorder.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-39, 42, 45 (Case Study and Nursing Care Plan, Borderline Personality Disorder
TOP: Nursing Process: Diagnosis/Analysis
MSC: Client Needs: Psychosocial Integrity
16. Which statement made by a patient diagnosed with borderline personality disorder indicates the
treatment plan is effective?
a. ―I think you are the best nurse on the unit.‖
b. ―I‘m never going to get high on drugs again.‖
c. ―I felt empty and wanted to hurt myself, so I called you.‖
d. ―I hate my mother. I called her today, and she wasn‘t home.‖
ANS: C
Seeking a staff member instead of impulsively self-mutilating shows an adaptive coping
strategy. The incorrect responses demonstrate idealization, devaluation, and wishful thinking.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 24-45 (Case Study and Nursing Care Plan, Borderline Personality Disorder), 50 TOP:
Nursing Process: Evaluation
MSC: Client Needs: Psychosocial Integrity
17. When preparing to interview a patient diagnosed with narcissistic personality disorder, a nurse
can anticipate the assessment findings will include
a. preoccupation with minute details; perfectionist.
b. charm, drama, seductiveness; seeking admiration.
c. difficulty being alone; indecisive, submissiveness.
d. grandiosity, self-importance, and a sense of entitlement.
ANS: D
The characteristics of grandiosity, self-importance, and entitlement are consistent with
narcissistic personality disorder. Charm, drama, seductiveness, and admiration seeking are
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seen in patients with histrionic personality disorder. Preoccupation with minute details and
perfectionism are seen in individuals with obsessive-compulsive personality disorder. Patients
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with dependent personality disorder often express difficulty being alone and are indecisive
and submissive.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-15, 16
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
18.
For which behavior would limit setting be most essential? The patient who
a. clings to the nurse and asks for advice about inconsequential matters.
b. is flirtatious and provocative with staff members of the opposite sex.
c. is hypervigilant and refuses to attend unit activities.
d. urges a suspicious patient to hit anyone who stares.
ANS: D
This is a manipulative behavior. Because manipulation violates the rights of others, limit
setting is absolutely necessary. Furthermore, limit setting is necessary in this case because the
safety of at least two other patients is at risk. Limit setting may occasionally be used with
dependent behavior (clinging to the nurse) and histrionic behavior (flirting with staff
members), but other therapeutic techniques are also useful. Limit setting is not needed for a
patient who is hypervigilant and refuses to attend unit activities; rather, the need to develop
trust is central to patient compliance.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 24-58 (Table 24-1), 66 (Box 24-2)
TOP: Nursing Process: Planning MSC:
Client Needs: Safe, Effective Care Environment
19. The nurse caring for an individual demonstrating symptoms of schizotypal personality disorder
would expect assessment findings to include
a. arrogant, grandiose, and a sense of self-importance.
b. attention seeking, melodramatic, and flirtatious.
c. impulsive, restless, socially aggressive behavior.
d. socially anxious, rambling stories, peculiar ideas.
ANS: D
Individuals with schizotypal personality disorder do not want to be involved in relationships.
They are shy and introverted, speak little, and prefer fantasy and daydreaming to being
involved with real people. The other behaviors would characteristically be noted in
narcissistic, histrionic, and antisocial personality disorder. (The educator may reformat this
question as multiple response.)
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-11, 12
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
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20. Others describe a worker as very shy and lacking in self-confidence. This worker stays in an
office cubicle all day, never coming out for breaks or lunch. Which term best describes this
behavior?
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Halter |Test Bank|Chapter 1-36 UPDATED 2022
a.
b.
c.
d.
Narcissistic
Histrionic
Avoidant
Paranoid
ANS: C
Patients with avoidant personality disorder are timid, socially uncomfortable, withdrawn, and
avoid situations in which they might fail. They believe themselves to be inferior and
unappealing. Individuals with histrionic personality disorder are seductive, flamboyant,
shallow, and attention-seeking. Paranoia and narcissism are not evident.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-17, 18
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
21. What is the priority intervention for a nurse beginning to work with a patient diagnosed with a
schizotypal personality disorder?
a. Respect the patient‘s need for periods of social isolation.
b. Prevent the patient from violating the nurse‘s rights.
c. Teach the patient how to select clothing for outings.
d. Engage the patient in community activities.
ANS: A
Patients with schizotypal personality disorder are eccentric and often display perceptual and
cognitive distortions. They are suspicious of others and have considerable difficulty trusting.
They become highly anxious and frightened in social situations, thus the need to respect their
desire for social isolation. Teaching the patient to match clothing is not the priority
intervention. Patients with schizotypal personality disorder rarely engage in behaviors that
violate the nurse‘s rights or exploit the nurse.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-12, 13
TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
22. A patient diagnosed with borderline personality disorder self-inflicted wrist lacerations after
gaining new privileges on the unit. In this case, the self-mutilation may have been due to a. an
inherited disorder that manifests itself as an incapacity to tolerate stress.
b. use of projective identification and splitting to bring anxiety to manageable levels.
c. a constitutional inability to regulate affect, predisposing to psychic disorganization.
d. fear of abandonment associated with progress toward autonomy and independence.
ANS: D
Fear of abandonment is a central theme for most patients with borderline personality disorder.
This fear is often exacerbated when patients with borderline personality disorder experience
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success or growth.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
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REF: Pages 24-33, 43
TOP: Nursing Process: Evaluation
MSC: Client Needs: Safe, Effective Care Environment
23. A patient diagnosed with borderline personality disorder has self-inflicted wrist lacerations. The
health care provider prescribes daily dressing changes. The nurse performing this care should
a. maintain a stern and authoritarian affect.
b. provide care in a matter-of-fact manner.
c. encourage the patient to express anger.
d. be very rigid and challenging.
ANS: B
A matter-of-fact approach does not provide the patient with positive reinforcement for selfmutilation. The goal of providing emotional consistency is supported by this approach. The
distracters provide positive reinforcement of the behavior or fail to show compassion.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-47, 48
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
24. A nurse set limits while interacting with a patient demonstrating behaviors associated with
borderline personality disorder. The patient tells the nurse, ―You used to care about me. I
thought you were wonderful. Now I can see I was wrong. You‘re evil.‖ This outburst can be
assessed as a. denial.
b. splitting.
c. defensive.
d. reaction formation.
ANS: B
Splitting involves loving a person, then hating the person because the patient is unable to
recognize that an individual can have both positive and negative qualities. Denial is
unconsciously motivated refusal to believe something. Reaction formation involves
unconsciously doing the opposite of a forbidden impulse. The scenario does not indicate
defensiveness.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-32, 33
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
25. Which characteristic of personality disorders makes it most necessary for staff to schedule
frequent team meetings in order to address the patient‘s needs and maintain a therapeutic
milieu?
a. Ability to achieve true intimacy
b. Flexibility and adaptability to stress
c. Ability to provoke interpersonal conflict
d. Inability to develop trusting relationships
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ANS: C
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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Frequent team meetings are held to counteract the effects of the patient‘s attempts to split staff
and set them against one another, causing interpersonal conflict. Patients with personality
disorders are inflexible and demonstrate maladaptive responses to stress. They are usually
unable to develop true intimacy with others and are unable to develop trusting relationships.
Although problems with trust may exist, it is not the characteristic that requires frequent staff
meetings.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-44, 45
TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
26. A nursing diagnosis appropriate to consider for a patient diagnosed with any of the personality
disorders is
a. nonadherence.
b. impaired social interaction.
c. disturbed personal identity.
d. diversional activity deficit.
ANS: B
Without exception, individuals with personality disorders have problems with social
interaction with others; hence, the diagnosis of ―impaired social interaction.‖ For example,
some individuals are suspicious and lack trust, others are avoidant, and still others are
manipulative. None of the other diagnoses are universally applicable to patients with
personality disorders; each might apply to selected clinical diagnoses, but not to others.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-2, 3
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
27. A new psychiatric technician says, ―Schizophrenia … schizotypal! What‘s the difference?‖ The
nurse‘s response should include which information?
a. A patient diagnosed with schizophrenia is not usually overtly psychotic.
b. In schizotypal personality disorder, the patient remains psychotic much longer.
c. With schizotypal personality disorder, the person can be made aware of misinterpretations
of reality.
d. Schizotypal personality disorder causes more frequent and more prolonged
hospitalizations than schizophrenia.
ANS: C
The patient with schizotypal personality disorder might have problems thinking, perceiving,
and communicating and might have an odd, eccentric appearance; however, they can be made
aware of misinterpretations and overtly psychotic symptoms are usually absent. The
individual with schizophrenia is more likely to display psychotic symptoms, remain ill for
longer periods, and have more frequent and prolonged hospitalizations.
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PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 2412 TOP: Nursing Process: Implementation
MSC: Client Needs:
Psychosocial Integrity
28. Personality traits most likely to be documented regarding a patient demonstrating characteristics
of an obsessive-compulsive personality disorder are a. affable, generous.
b. perfectionist, inflexible.
c. suspicious, holds grudges.
d. dramatic speech, impulsive.
ANS: B
The individual with obsessive-compulsive personality disorder is perfectionist, rigid,
preoccupied with rules and procedures, and afraid of making mistakes. The other options refer
to behaviors or traits not usually associated with OCPD.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-21, 22
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
29. A nurse determines desired outcomes for a patient diagnosed with schizotypal personality
disorder. Select the best outcome. The patient will a. adhere willingly to unit norms.
b. report decreased incidence of self-mutilative thoughts.
c. demonstrate fewer attempts at splitting or manipulating staff.
d. demonstrate ability to introduce self to a stranger in a social situation.
ANS: D
Schizotypal individuals have poor social skills. Social situations are uncomfortable for them.
It is desirable for the individual to develop the ability to meet and socialize with others.
Individuals with schizotypal PD (Personality Disorder) usually have no issues with adherence
to unit norms, nor are they self-mutilative or manipulative.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 24-12 and 24-13
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
30. A patient says, ―The other nurses won‘t give me my medication early, but you know what it‘s
like to be in pain and don‘t let your patients suffer. Could you get me my pill now? I won‘t tell
anyone.‖ Which response by the nurse would be most therapeutic?
a. ―I‘m not comfortable doing that,‖ and then ignore subsequent requests for early
medication.
b. ―I understand that you have pain, but giving medicine too soon would not be safe.‖
c. ―I‘ll have to check with your doctor about that; I will get back to you after I do.‖
d. ―It would be unsafe to give the medicine early; none of us will do that.‖
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ANS: B
The patient is attempting to manipulate the nurse. Empathetic mirroring reflects back to the
patient the nurse‘s understanding of the patient‘s distress or situation in a neutral manner that
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does not judge it and helps elicit a more positive response to the limit that is being set. The
other options would not be nontherapeutic; they lack the empathetic mirroring component that
tends to elicit a more positive response from the patient.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 24-30, 44, 60 (Table 24-2)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A nurse plans care for an individual diagnosed with antisocial personality disorder. Which
characteristic behaviors will the nurse expect? (Select all that apply.) a. Reclusive behavior
b. Callous attitude
c. Perfectionism
d. Aggression
e. Clinginess
f. Anxiety
ANS: B, D
Individuals with antisocial personality disorders characteristically demonstrate manipulative,
exploitative, aggressive, callous, and guilt-instilling behaviors. Individuals with antisocial
personality disorders are more extroverted than reclusive, rarely show anxiety, and rarely
demonstrate clinging or dependent behaviors. Individuals with antisocial personality disorders
are more likely to be impulsive than to be perfectionists.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-23 to 25
TOP: Nursing Process: Assessment MSC: Client
Needs: Psychosocial Integrity
2. For which patients diagnosed with personality disorders would a family history of similar
problems be most likely? (Select all that apply.) a. Obsessive-compulsive
b. Antisocial
c. Borderline
d. Schizotypal
e. Narcissistic
ANS: A, B, C, D
Some personality disorders have evidence of genetic links, so the family history would show
other members with similar traits. Heredity plays a role in schizotypal, antisocial, borderline,
and obsessive-compulsive personality disorder.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 24-9, 21, 26, 37
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
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Chapter 25: Suicide and Nonsuicidal Self-Injury
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1.
An adult outpatient diagnosed with major depressive disorder has a history of several suicide
attempts by overdose. Given this patient‘s history and diagnosis, which antidepressant
medication would the nurse expect to be prescribed? a. Amitriptyline
b. Fluoxetine
c. Desipramine
d. Tranylcypromine sulfate
ANS: B
Selective serotonin reuptake inhibitor antidepressants are very safe in overdosage situations,
which is not true of the other medications listed. Given this patient‘s history of overdosing, it
is important that the medication be as safe as possible in the event of another overdose of
prescribed medication.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 25-25, 26
TOP: Nursing Process: Planning
MSC: Client Needs: Physiological Integrity
2.
Four individuals have given information about their suicide plans. Which plan evidences the
highest suicide risk?
a. Turning on the oven and letting gas escape into the apartment during the night
b. Cutting the wrists in the bathroom while the spouse reads in the next room
c. Overdosing on aspirin with codeine while the spouse is out with friends
d. Jumping from a railroad bridge located in a deserted area late at night
ANS: D
This is a highly lethal method with little opportunity for rescue. The other options are lower
lethality methods with higher rescue potential. See relationship to audience response question.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 25-15, 16
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
3.
Which measure would be considered a form of primary prevention for suicide?
a. Psychiatric hospitalization of a suicidal patient
b. Referral of a formerly suicidal patient to a support group
c. Suicide precautions for 24 hours for newly admitted patients
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d. Helping school children learn to manage stress and be resilient
ANS: D
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This measure promotes effective coping and reduces the likelihood that such children will
become suicidal later in life. Admissions and suicide precautions are secondary prevention
measures. Support group referral is a tertiary prevention measure.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 25-17, 18, 54 (Box 25-3)
TOP: Nursing Process: Implementation MSC:
Client Needs: Safe, Effective Care Environment
4.
Which change in the brain‘s biochemical function is most associated with suicidal behavior? a.
Dopamine excess
b. Serotonin deficiency
c. Acetylcholine excess
d. γ-aminobutyric acid deficiency
ANS: B
Research suggests that low levels of serotonin may play a role in the decision to commit
suicide. The other neurotransmitter alterations have not been implicated in suicidality.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 25-7
TOP: Nursing Process: Assessment MSC: Client Needs: Physiological
Integrity
5.
A college student who failed two tests cried for hours and then tried to telephone a parent but
got no answer. The student then gave several expensive sweaters to a roommate and asked to be
left alone for a few hours. Which behavior provides the strongest clue of an impending suicide
attempt?
a. Calling parents
b. Excessive crying
c. Giving away sweaters
d. Staying alone in dorm room
ANS: C
Giving away prized possessions may signal that the individual thinks he or she will have no
further need for the item, such as when a suicide plan has been formulated. Calling parents,
remaining in a dorm, and crying do not provide direct clues to suicide.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 25-14 TOP:
Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
6.
A nurse uses the SAD PERSONS scale to interview a patient. This tool provides data relevant
to
a. current stress level.
b. mood disturbance.
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c. suicide potential.
d. level of anxiety.
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ANS: C
The SAD PERSONS tool evaluates 10 major risk factors in suicide potential: sex, age,
depression, previous attempt, ethanol use, rational thinking loss, social supports lacking,
organized plan, no spouse, and sickness. The tool does not have categories to provide
information on the other options listed.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 25-17, 47 (Table 25-2)
TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
7.
A person intentionally overdosed on antidepressants. Which nursing diagnosis has the highest
priority?
a. Powerlessness
b. Social isolation
c. Risk for suicide
d. Compromised family coping
ANS: C
This diagnosis is the only one with life-or-death ramifications and is therefore of higher
priority than the other options.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-17, 47 (Table 25-2)
TOP: Nursing Process: Diagnosis/Analysis MSC:
Client Needs: Psychosocial Integrity
8.
A person who attempted suicide by overdose was treated in the emergency department and then
hospitalized. The initial outcome is that the patient will
a. verbalize a will to live by the end of the second hospital day.
b. describe two new coping mechanisms by the end of the third hospital day.
c. accurately delineate personal strengths by the end of first week of hospitalization.
d. exercise suicide self-restraint by refraining from attempts to harm self for 24 hours.
ANS: D
Suicide self-restraint relates most directly to the priority problem of risk for self-directed
violence. The other outcomes are related to hope, coping, and self-esteem.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-18 (Case Study and Nursing Care Plan), 38, 47 (Table 25-2) TOP:
Nursing Process: Outcomes Identification
MSC: Client Needs: Psychosocial Integrity
9.
A college student who attempted suicide by overdose was hospitalized. When the parents were
contacted, they responded, ―We should have seen this coming. We did not do enough.‖ The
parents‘ reaction reflects a. guilt.
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b. denial.
c. shame.
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d. rescue feelings.
ANS: A
The parents‘ statements indicate guilt. Guilt is evident from the parents‘ self-chastisement.
The feelings suggested in the distracters are not clearly described in the scenario.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 25-7
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial
Integrity
10. Select the most critical question for the nurse to ask an adolescent who has threatened to take an
overdose of pills.
a. ―Why do you want to kill yourself?‖
b. ―Do you have access to medications?‖
c. ―Have you been taking drugs and alcohol?‖
d. ―Did something happen with your parents?‖
ANS: B
The nurse must assess the patient‘s access to means to carry out the plan and, if there is
access, alert the parents to remove from the home and take additional actions to assure the
patient‘s safety. The information in the other questions may be important to ask but are not the
most critical.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Pages 25-15,
16, 47 (Table 25-2), 52 (Box 25-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
11. It has been 5 days since a suicidal patient was hospitalized and prescribed an antidepressant
medication. The patient is now more talkative and shows increased energy. Select the highest
priority nursing intervention.
a. Supervise the patient 24 hours a day.
b. Begin discharge planning for the patient.
c. Refer the patient to art and music therapists.
d. Consider discontinuation of suicide precautions.
ANS: A
The patient now has more energy and may have decided on suicide, especially given the prior
suicide attempt history. The patient must be supervised 24 hours per day. The patient is still a
suicide risk.
PTS: 1 DIF: Cognitive Level: Apply (Application) REF: Page 25-14 TOP:
Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
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12. A nurse and patient construct a no-suicide contract. Select the preferable wording.
a. ―I will not try to harm myself during the next 24 hours.‖
b. ―I will not make a suicide attempt while I am hospitalized.‖
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c. ―For the next 24 hours, I will not in any way attempt to harm or kill myself.‖
d. ―I will not kill myself until I call my primary nurse or a member of the staff.‖
ANS: C
The correct answer leaves no loopholes. The wording about not harming oneself and not
making an attempt leaves loopholes or can be ignored by the patient who thinks ―I am not
going to harm myself, I am going to kill myself‖ or ―I am not going to attempt suicide, I am
going to commit suicide.‖ A patient may call a therapist and leave the telephone to carry out
the suicidal plan.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 25-14 (Table 26-5) TOP: Nursing Process: Implementation MSC: Client
Needs: Safe, Effective Care Environment
13. A tearful, anxious patient at the outpatient clinic reports, ―I should be dead.‖ The initial task of
the nurse conducting the assessment interview is to a. assess lethality of suicide plan.
b. encourage expression of anger.
c. establish trust with the patient.
d. determine risk factors for suicide.
ANS: C
This scenario presents a potential crisis. Establishing trust facilitates a therapeutic alliance that
will allow the nurse to obtain relevant assessment data such as the presence of a suicide plan,
lethality of plan, and presence of risk factors for suicide.
PTS: 1
DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 25-18 (Case Study and Nursing Care Plan), 24, 39
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
14. A nurse interacts with an outpatient who has a history of multiple suicide attempts. Select the
most helpful response for a nurse to make when the patient states, ―I am considering
committing suicide.‖
a. ―I‘m glad you shared this. Please do not worry. We will handle it together.‖
b. ―I think you should admit yourself to the hospital to keep you safe.‖
c. ―Bringing up these feelings is a very positive action on your part.‖
d. ―We need to talk about the good things you have to live for.‖
ANS: C
The correct response gives the patient reinforcement, recognition, and validation for making a
positive response rather than acting out the suicidal impulse. It gives neither advice nor false
reassurance, and it does not imply stereotypes such as ―You have a lot to live for.‖ It uses the
patient‘s ambivalence and sets the stage for more realistic problem solving.
PTS: 1
DIF: Cognitive Level: Apply (Application)
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REF: Pages 25-18 (Case Study and Nursing Care Plan), 24
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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15. Which intervention will the nurse recommend for the distressed family and friends of someone
who has committed suicide?
a. Participating in reminiscence therapy
b. Psychological postmortem assessment
c. Attending a self-help group for survivors
d. Contracting for at least two sessions of group therapy
ANS: C
Survivors need outlets for their feelings about the loss and the deceased person. Self-help
groups provide peer support while survivors work through feelings of loss, anger, and guilt.
Psychological postmortem assessment would not provide the support necessary to work
through feelings of loss associated with the suicide. Reminiscence therapy is not geared to
loss resolution. Contracting for two sessions of group therapy would not provide sufficient
time to work through the issues associated with a death by suicide.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-7, 31
TOP: Nursing Process: Implementation MSC: Client
Needs: Psychosocial Integrity
16. Which statement provides the best rationale for closely monitoring a severely depressed patient
during antidepressant medication therapy?
a. As depression lifts, physical energy becomes available to carry out suicide.
b. Patients who previously had suicidal thoughts need to discuss their feelings.
c. For most patients, antidepressant medication results in increased suicidal thinking.
d. Suicide is an impulsive act. Antidepressant medication does not alter impulsivity.
ANS: A
Antidepressant medication has the objective of relieving depression. Risk for suicide is
greater as the depression lifts, primarily because the patient has more physical energy at a
time when he or she may still have suicidal ideation. The other options have little to do with
nursing interventions relating to antidepressant medication therapy.
PTS: 1 DIF: Cognitive Level: Understand (Comprehension) REF: Page 25-14
TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
17. A nurse assesses a patient who reports a 3-week history of depression and periods of
uncontrolled crying. The patient says, ―My business is bankrupt, and I was served with divorce
papers.‖ Which subsequent statement by the patient alerts the nurse to a concealed suicidal
message?
a. ―I wish I were dead.‖
b. ―Life is not worth living.‖
c. ―I have a plan that will fix everything.‖
d. ―My family will be better off without me.‖
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ANS: C
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Verbal clues to suicide may be overt or covert. The incorrect options are overt references to
suicide. The correct option is more veiled. It alludes to the patient‘s suicide as being a way to
―fix everything‖ but does not say it outright.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-12, 13, 47 (Table 25-2) TOP: Nursing Process: Assessment MSC:
Client Needs: Psychosocial Integrity
18. A depressed patient says, ―Nothing matters anymore.‖ What is the most appropriate response by
the nurse?
a. ―Are you having thoughts of suicide?‖
b. ―I am not sure I understand what you are trying to say.‖
c. ―Try to stay hopeful. Things have a way of working out.‖
d. ―Tell me more about what interested you before you became depressed.‖
ANS: A
The nurse must make overt what is covert; that is, the possibility of suicide must be openly
addressed. The patient often feels relieved to be able to talk about suicidal ideation.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-12, 13, 18 (Case Study and Nursing Care Plan), 47 (Table 25-2)
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
19. A nurse counsels a patient with recent suicidal ideation. Which is the nurse‘s most therapeutic
comment?
a. ―Let‘s make a list of all your problems and think of solutions for each one.‖
b. ―I‘m happy you‘re taking control of your problems and trying to find solutions.‖
c. ―When you have bad feelings, try to focus on positive experiences from your life.‖
d. ―Let‘s consider which problems are very important and which are less important.‖
ANS: D
The nurse helps the patient develop effective coping skills. Assist the patient to reduce the
overwhelming effects of problems by prioritizing them. The incorrect options continue to
present overwhelming approaches to problem solving.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Page 25-18 (Case Study and Nursing Care Plan)
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
20. When assessing a patient‘s plan for suicide, what aspect has priority?
a. Patient‘s financial and educational status
b. Patient‘s insight into suicidal motivation
c. Availability of means and lethality of method
d. Quality and availability of patient‘s social support
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ANS: C
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Test Bank Varcarolis' Foundations of Psychiatric-Mental
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If a person has plans that include choosing a method of suicide readily available and if the
method is one that is lethal (i.e., will cause the person to die with little probability for
intervention), the suicide risk is high. These areas provide a better indication of risk than the
areas mentioned in the other options. See relationship to audience response question.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-15, 16
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe, Effective Care Environment
21. The feeling experienced by a patient that should be assessed by the nurse as most predictive of
elevated suicide risk is a. hopelessness.
b. sadness.
c. elation.
d. anger.
ANS: A
Of the feelings listed, hopelessness is most closely associated with increased suicide risk.
Depression, aggression, impulsivity, and shame are other feelings noted as risk factors for
suicide.
PTS: 1
DIF: Cognitive Level: Understand (Comprehension)
REF: Pages 25-4, 7, 16, 17, 18 (Case Study and Nursing Care Plan), 47 (Table 25-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
22. Which statement by a depressed patient will alert the nurse to the patient‘s need for immediate,
active intervention?
a. ―I am mixed up, but I know I need help.‖
b. ―I have no one to turn to for help or support.‖
c. ―It is worse when you are a person of color.‖
d. ―I tried to get attention before I cut myself last time.‖
ANS: B
Hopelessness is evident. Lack of social support and social isolation increases the suicide risk.
Willingness to seek help lowers risk. Being a person of color does not suggest higher risk
because more whites commit suicide than do individuals of other racial groups. Attention
seeking is not correlated with higher suicide risk.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-4, 5, 16, 17, 18 (Case Study and Nursing Care Plan), 47 (Table 25-2)
TOP: Nursing Process: Planning
MSC: Client Needs: Safe, Effective Care Environment
23. A patient previously hospitalized for 2 weeks committed suicide the day after discharge. Which
initial nursing measure will be most important regarding this event?
a. Request the information technology manager to verify the patient‘s medical record is
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secure in the hospital information system.
b. Hold a meeting for staff to provide support, express feelings, and identify overlooked
clues or faulty judgments.
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c. Consult the hospital‘s legal department regarding potential consequences of the event.
d. Document a report of a sentinel event in the patient‘s medical record.
ANS: B
Support and an opportunity for staff to safely express feelings about the event should occur
first. Interventions should help the staff come to terms with the loss and grow because of the
incident. Identifying overlooked clues or faulty judgments will provide the groundwork for
identifying changes needed in policies and procedures for future patients. Consulting the legal
department is not an initial measure. A sentinel event report is not part of the medical record
and can be prepared later. The other incorrect options will not control information or would
result in unsafe care.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-31, 32
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
24. After one of their identical twin daughters commits suicide, the parents express concern that
the other twin may also have suicidal tendencies. Which reply should the nurse provide? a.
―Genetics are associated with suicide risk. Monitoring and support are important.‖
b. ―Apathy underlies suicide. Instilling motivation is the key to health maintenance.‖
c. ―Your child is unlikely to act out suicide when identifying with a suicide victim.‖
d. ―Fraternal twins are at higher risk for suicide than identical twins.‖
ANS: A
Twin studies suggest the presence of genetic factors in suicide; however, separating genetic
predisposition to suicide from predisposition to depression or alcoholism is difficult. Primary
interventions can be helpful in promoting and maintaining health and possibly counteracting
genetic load. The incorrect options are untrue statements or an oversimplification.
PTS: 1
DIF: Cognitive Level: Apply (Application)
REF: Pages 25-6, 7
TOP: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
25. Which individual in the emergency department should be considered at highest risk for
completing suicide?
a. An adolescent Asian American girl with superior athletic and academic skills who has
asthma
b. A 38-year-old single, African American female church member with fibrocystic breast
disease
c. A 60-year-old married Hispanic man with 12 grandchildren who has type 2 diabetes
d. A 79-year-old single, white male diagnosed recently with terminal cancer of the
prostate
ANS: D
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High-risk factors include being an older adult, single, male, and having a co-occurring
medical illness. Cancer is one of the somatic conditions associated with increased suicide risk.
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Protective factors for African American women and Hispanic individuals include strong
religious and family ties. Asian Americans have a suicide rate that increases with age.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 25-5, 6,
50 (Box 25-1), 52 (Box 25-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
1. A nurse assesses five newly hospitalized patients. Which patients have the highest suicide risk?
(Select all that apply.) a. 82-year-old white male
b. 17-year-old white female
c. 22-year-old Hispanic male
d. 19-year-old Native American male
e. 39-year-old African American male
ANS: A, B, D
Whites have suicide rates almost twice those of nonwhites, and the rate is particularly high for
older adult males, adolescents, and young adults. Other high-risk groups include young
African American males, Native American males, and older Asian Americans. Rates are not
high for Hispanic males.
PTS: 1 DIF: Cognitive Level: Analyze (Analysis)
REF: Pages 25-5, 6,
50 (Box 25-1), 52 (Box 25-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
2. Which nursing interventions will be implemented for a patient who is actively suicidal?
(Select all that apply.)
a. Maintain arm‘s length, one-on-one direct observation at all times.
b. Check all items brought by visitors and remove risk items.
c. Use plastic eating utensils; count utensils upon collection.
d. Remove the patient‘s eyeglasses to prevent self-injury.
e. Interact with the patient every 15 minutes.
ANS: A, B, C
One-on-one observation is necessary for anyone who has limited or unreliable control over
suicidal impulses. Finger foods allow the patient to eat without silverware; ―no silver or
glassware‖ orders restrict access to a potential means of self-harm. Every-15-minute checks
are inadequate to assure the safety of an actively suicidal person. Placement in a public area is
not a substitute for arm‘s-length direct observation; some patients will attempt suicide even
when others are nearby. Vision impairment requires eyeglasses (or contacts); although they
could be used dangerously, watching the patient from arm‘s length at all times would allow
enough time to interrupt such an attempt and would prevent the disorientation and isolation
that uncorrected visual impairment could create.
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PTS: 1 DIF: Cognitive Level: Apply (Application)
16, 47 (Table 25-2), 52 (Box 25-2)
REF: Pages 25-15,
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TOP: Nursing Process: Implementation
MSC: Client Needs: Safe, Effective Care Environment
3. A college student is extremely upset after failing two examinations. The student said, ―No one
understands how this will hurt my chances of getting into medical school.‖ The student then
suspends access to his social networking website and turns off his cell phone. Which suicide
risk factors are evident? (Select all that apply.) a. Shame
b. Panic attack
c. Humiliation
d. Self-imposed isolation
e. Recent stressful life event
ANS: A, C, D, E
Failing examinations in the academic major constitutes a recent stressful life event. Shame
and humiliation related to the failure can be hypothesized. The statement, ―No one can
understand,‖ can be seen as recent lack of social support. Terminating access to one‘s social
networking site and turning off the cell phone represents self-imposed isolation. The scenario
does not provide evidence of panic attack.
PTS: 1 DIF: Cognitive Level: Apply (Application)
REF: Pages 25-5, 6,
50 (Box 25-1), 52 (Box 25-2)
TOP: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
Chapter 26: Crisis and Disaster
Halter: Varcarolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical
Approach, 8th Edition
MULTIPLE CHOICE
1.
A patient comes to the crisis clinic after an unexpected job termination. The patient paces, sobs,
cringes when approached, and responds to questions with only shrugs or monosyllables.
Choose the nurse‘s best initial comment to this patient.
a. ―Everything is going to be all right. You are here at the clinic and the staff will keep you
safe.‖
b. ―I see you are feeling upset. I‘m going to stay and talk with you to help you feel better.‖
c. ―You need to try to stop crying and pacing so we can talk about your problems.‖
d. ―Let‘s set some guidelines and goals for your visit here.‖
ANS: B
A crisis exists for this patient. The two primary thrusts of crisis intervention are to provide for
the safety of the individual and use anxiety-reduction techniques to facilitate use of inner
resources. The nurse offers therapeutic presence, which provides caring, ongoing observation
relative to the patient‘s safety, and interpersonal reassurance.
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